Access to care

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He always has a piece of paper in front of his mouth when he talks which makes it hard to hear. He also hisses like a vampire a lot. I would not recommend this class.

Rate My Professors, actual comment

The consumerisation of student opinion: there’s gold in those hills, for sure. In 1999, a Californian software engineer created teacherratings.com to aggregate college student reviews of individual college professors, and the site became ratemyprofessors.com in 2001. In 2005 ratemyprofessors.com, was sold, and then sold again in January 2007 “for an undisclosed sum” to mtvU, a Viacom subsidiary. This wasn’t the only item in the shopping cart. Recognising the captive commercial value of the campus student market, Viacom were hunting channels, brands and products that would enable them to bracket the social and consumer dimensions of being a student to their other entertainment investments. mtvU promotes among its popular shows Professors Strike Back, redirecting users back to RMP (click!) to see video clips of academics reading their reviews aloud, where they can also take a moment to rate their favourite professors from the movies (click!).

It’s feedback, on $tilt$.

So at one level, RMP is a story of extraordinary personal success. Patrick Nagle (Internet Enthusiast, Dealmaker), who bought and sold RMP and also owns Rate My Teacher (“helps students, parents and teachers make informed decisions by promoting transparency within education”), is 33 years old. He has been buying and selling internet real estate since he was 16. He’s a role model for young entrepreneurs and innovators. He makes stuff, and makes stuff happen. It’s just that in Rate My Professors, what he has made happen is complex at the human level, and ethically fraught.

Let’s get the big distraction out of the way: Rate My Professors leans on Likert scales like they’re going out of fashion, and true to its current corporate home in the entertainment world, rate my professor screenshotit still rates professors on their hotness. Yup, this is what you think, with a chilli pepper. And even if you’re OK with this as a harmless bit of internet lint, RMP is now such big business that its annual rankings of the top college professors in the US pop up all over the place, including through cross-promotion via other Viacom products. So if you link back into the site (click!) from a seemingly serious national ranking of professional standing and start browsing, there it is: you’re staring at a professional colleague’s hotness rating, and that’s an actual thing now.

And suddenly you remember everything about the sophomorish social origins of Facebook as a hot-or-not student rating site, and the hopeless commentary on women as sexual distractions in science labs, and everything we know about role congruity perceptions in the evaluation of performance, and every comment you’ve ever read that’s focused on appearance not performance. It’s tiring, and sad, and dealing with it is exactly what Audrey Watters recognises as the affective labour of higher education that won’t be replaced by a machine any time soon.

(The three professional factors that are included in the rating itself that are more obviously about teaching are helpfulness, clarity and easiness. Some comments valiantly defend the idea that a thing that’s hard isn’t necessarily what you came to college to avoid, but there’s a powerfully visible aggregation of sentiment around fairness that mentions how easy it is to get a good grade from this person.)

And wait, there’s more. The rating of individual professors has now expanded to be the basis on which RMP rates whole colleges. Hello, college rankings! What we have here is an uncontrolled brand situation, that will draw in the social media teams who keep a very close eye on this kind of malarkey. And when they get there, what do they see but the very professors who are holding up the averages, and those who Rate My Professors screenshotappear to be holding them back. Suddenly those who are hissing like vampires, or grading too harshly, or are difficult to contact because they have 400 students in a gen ed class, or are working three teaching jobs across town while holding office hours in their car, or who have an invisible disability, or a kid in hospital, or a class that was dropped in their lap because someone else pulled out, are right there in a handy list.

And if it turns out that one or two have a red grumpy face by their name, how could you possibly not remember that when hiring comes around?

Because this is really what bites about both formal SETs, and informal but immensely powerful and profitable reviewing platforms like RMP: in a majority casualised workforce, the reform of service delivery that disappointed consumers seek is simplest to achieve by not hiring a person again. US higher education is only patchily unionised which makes not hiring of an adjunct pretty easy; even in Australia it would be very hard for a casual academic to prove that not being hired was the direct result of an unfavourable evaluation, when the labour market is at saturation point, and then some.

What can we do better? This week while worrying generally about the ethics of customer service reviews in higher education, I’ve been thinking about good examples from healthcare, and a heartbreaking but really important example from Veterans Affairs.

There are several organisations working to solicit and pass on patient feedback, on both good and bad experiences. The best of these, I think, is Patient Opinion, and the Australian site is here. A recent example of how effectively and thoughtfully they reflect on whether they serve organisations or patients is in their blog here. They argue that organisations solicit service user feedback in part to limit risk; while patients are cautious about being labelled difficult if they complain. As an intermediary in this often confronting environment, Patient Opinion is focused on doing better—on building a reflective relationship around critical care incidents, not just a complaints forum. It’s a really good model for higher education.

But there are no short cuts to this model. Real change doesn’t come from one-sided feedback, but from negotiated relationships built on trust and reciprocal respect, and this is a point made in a useful post from the Cancer Geek blog, “Does Healthcare Need Cooperation or Collaboration?

Collaboration requires all involved stakeholders to listen to one another, define the problem together, and understand the expectations and requirements for what a successful outcome will look like upon completion. Collaboration takes time, effort, and commitment.

Time, effort, commitment.

What would it take in time-impoverished institutions like public universities or hospitals for their service users to be fully and respectfully included in the story of what is being done to provide the service? How can our reputation-mad institutions take the risk of sharing with students the way that they’re cutting service costs? How can academic staff conscientiously and professionally deal with the affective cost of austerity budgeting while trying to do a good thing in the room, in the grading, in the vanishing time for consultation?

While you’re thinking about this, and perhaps while you’re thinking of reviewing a service incident—either as a patient, or a student—take one minute and listen to a VA employee and a veteran break down together on the phone over access to care. They’re both exhausted, and weeping, and neither of them is wrong, and everything is wrong, and at the end, this is what the veteran has to say about what happened:

“I want to give that fucking woman a hug. I just want to tell her that I know it’s not her fault. I wish she hadn’t hung up the phone.”

Think like this.

21 thoughts on “Access to care

  1. Another great post, I can hardly wait for them to start rating uni’s here like that, and as for the health care system, well they don’t listen to the complaints or any new ideas from consumers that would help, they often believe in themselves as being the font of all knowledge. That’s why some of the services backfire. It’s their way or the highway.

    1. The thing is, I think they do listen. Up to a point. Here’s a small story: I was asked what would have made a difference to my care, and I said that none of the patients know the names of the nurses delivering chemo to them. It’s a confronting experience, you’re sitting there with another human being who is barrier-dressed from top to toe in case the hugely poisonous drug they’re injecting right into your veins splashes on them, and you don’t even have a name for them. The next time I went to the unit, there was the cheapest possible solution: a large laminated sheet of paper stuck to the wall with the names of nurses on duty that morning in that area. I was really moved by this.

      But I think there are also people who are giving the impression of institutional deafness, and they believe this is the right way to defend their systems and themselves, and I really don’t know how we reach them to say: stop, think about the way you speak to us. We are all in here together, at this moment in our lives. Let’s not make things worse.

  2. I read a post like this and think that your mind must be made of stuff different than mine because even though I find all the points you make compelling and even enlightening, something is nagging at the back of my head and I don’t know what it is or how to express it. Will email you to see if you can help me through this! It’s based on several of your last posts.

    But mainly i wanted to thank you again for expanding and helping to deepen my thinking about so many things

    1. Since Maha is the one who sent me here I think her inner voice has something to say about this. For me, I’m with proudblacksista on the medical system avoiding complaints, though I think it should be extended to their obvious and self defeating habit of building walls around their unsustainable need to filter out feedback.

      The medical system I deal with probably falls into an actual psychiatric category denial of patient needs–their ‘Patient Concerns’ phone line is answered by a rather mean person as “Patient Complaints!!!” who is obviously mandated to get rid of you. And, if you argue with this person the next time you call the Patient Help nurse you will find yourself being refused service.

      I’d certainly like to see a change in this and tried approaching the clinic only to be shut down. My current strategy is to endure the “care” as much as can be taken in small bites but to understand that according to the medical system my cancer and heart defects are mine alone to deal with and no concern of theirs. Also, to be fair, the people I deal with are monsters of a system that twists their humanity day after day. It amazes me how we spend so much time and money training people to serve others and then situate them in a system DESIGNED to grind humans to pulp.

      1. Scott, welcome, it’s a delight to see you here. I’ve been aware of you for a while through Rebecca’s blog. I share your view completely: the systems that attempt to manage our care are also managing other people’s work in a way that makes it incredibly hard for them to do their job. Sure, there are wealthy health systems somewhere, but here in Australia as a public health system patient, I learned a great deal about how hospitals and universities are running on two ends of the same oily rag when it comes to underfunding.

        One night on the surgical ward a nurse came and sat on my bed, exhausted. I asked her about her work, and she told me something I’ve never forgotten about the rate of casualisation of ward nursing. What really stayed with me was the weariness of her hand gesture as she said ” … all this.”

        And oh yes, that moment where you see that “concerns” is a communications euphemism for “complaints”. The language we all use, it really matters.

    2. Right back to you, Maha. I’ve replied to your emails, but here too I just want to say publicly that the differences in our views on many things are really valuable to my thinking. I very much respect the conviction and perspective you bring to questions that don’t get asked enough, and these questions have been specifically helpful to me on many issues.

  3. All connected and shouldn’t be in silos. Cross comparisons like this help unlock them and break out of the ‘just for academics’ sand trap. My own perspective now includes the bureaucracy senior and aging services — and associated stereotypes (including those held by friends, family and colleagues who ought to know better). Consciously or unconsciously applied, the stereotypes and charges exercise social control and silencing over subject populations

    I’ve been watching this very rich pattern emerge in your recent posts and thinking about it too.

    1. Yes, yes, yes. I’ve just read an astonishing piece by one of Australia’s most distinguished historians, Inga Clendinnen, who is now in a nursing home, about her experiences there. It’s compassionate, rigorous, and targeted in its criticism of the way in which we silence and stereotype people who seem no longer productive, and whose care needs to be kept out of the way–while being very thoughtful and concerned for the younger, often migrant, women workers she sees day in day out. Siobhan O’Dwyer has really influenced my thinking on this–yours too.

  4. Rolling up to cat some pigeons

    I have upstairs a photocopied feedback form I submitted in year two of my degree to a module on Parallel Programming (1996) – I’ve moved house eight times since, but always kept it. I’d been told I needed to go to Uni, that I needed to work hard. I was stuck in a team programming module – where we were explicitly examined on teamwork, even though there was no actual assessment of it. I’d worked 14 hour days 7 days a week just to get the module done. I’d got chest pains, would sit at home drinking anti acids just to not be in pain. I’d pretty much decided I was done living. I wrote the word NO on a piece of A4 paper and stuck it on the ceiling above my bed just to talk myself out of things.

    I put down exactly what I thought about the course on 4 sheets of a4. The last thing I wrote was “and it tires me out giving you feedback as I can’t see how you yourself can’t see how bad this course is”. The course was ran by a Professor, 50 or so, who’d been in place 20 years or so.

    My course mates, mostly those from public schools just sat through stuff and never complained, and I guess, because they saw Uni as a mere stage in a predetermined destiny, whereas I was perpetually questioning its value. They had the wealth and contacts to walk into places and get work, whereas I’d have to go through all of the hoops to get near to that level of chance.

    Fast forward twenty years and I’m in North London, down and out again, looking for a new doctor. The local doctor has a triage phone system, and so you can’t get regular appointments, you have to call on the day and hope (no voicemail either, no call waiting, so if engaged, you have to call back. One day I called 35 times and never got an appointment). So when you’re on a meds cycle of two weeks, and coming of the meds is baaaaaaad, then not being able to schedule appointments is perhaps medically risky. So the next day I went to another GP near where I worked and waited 3 hours to speak to them because the receptionist forgot I was there. I was sitting in the reception.

    So I moved to another doctor, and went through the fortnightly cycle. I was due to get a referral to a psych unit, and the day I was due to get referred they kicked me off their books as I lived too far away. The only doctor I could use in my area wouldn’t have me at the time I need proper help. They knew what meds I was on, they knew I’d need repeats. But bad luck son, geography says otherwise.

    Now NHS Direct has a lovely website where you can provide feedback on your GP. Would I use it to provide feedback. No. Because I doubt it’d change anything anyways. If you can’t see how bad what they did was, then me telling them makes nothing but my time and keystrokes wasted.

    So as a left wing person, I sort of see education and the health service as charities I pay into but probably won’t use even if I needed to (bar emergencies).

    So I’d not defend ratemyprofessor, or anything like it, because the logic of a public service is that it should be developed didactically. However, if the system isn’t going to do this, then I’d question why it thinks it can take the money and expect nothing in return. My uni courses felt amateurish to the end, in a way my school never did. It is weird when a public service seems to be oddly institutionally sociopathic.

    If you listen, I can whisper, else don’t blame me for shouting

    1. Pat, I’m really thinking about this perception of institutional sociopathy. I think it’s important, but how do we see the humans in that institution as separate from its values? Are we really defined by the institutional values that we didn’t choose, and don’t pursue?

      I am really moved by your story.

      1. With our NHS, each GP can pretty much run by the own rules – opening hours, location, systems – so there is no “standard” provision. You can choose your own, offer it, and the the area around you has that service.

        So in my area in London
        1 Doctor opened 2 hours a day
        1 Doctor offered no appointments, you walked in and it was first come first served
        1 Doctor made you wait 1 month after registering before you could make an appointment

        So it isn’t an institution, it’s people. The fear GP receptionists give people is nigh on legendary. I wonder if it isn’t almost expected these days.

        I guess with universities the scale is different, but I think it becomes to easily persuasive to blame a bureaucratic other. Yesterday was exams results day at my old employer. My inbox is full of emails from students who can’t get to their results. Last year I replied to each email with guidance and instructions. This year no staff member has replied. I just replied to a few of them to help out.

        The institution isn’t controlling your desire to reply to people, you are. I can hear the conversations in the office now – “the students are stupid, they’ve been emailed instructions” as if that is enough to abdicate all emotions or need of help – “You’ve been taught to swim so if you drown *shrugs*”

        It’s one of the reasons I left. The culture was pretty much hatred. It knew it’d get new students, so who gives a fuck if the mill grinds a few out.

        Before I moved into academia I worked for social services. You never heard “turn a blind eye”, “who’ll find out” and “they’ll never know” in social services. Not because they had greater accountability (they did – every person we dealt with was recorded on a database) but because they just didn’t want to cut corners with other people’s lives. As those lives are next to you every single day.

        So perhaps ratemyprofessor and the like, are the rapid shortening of distance between people and problems. Same as with social media. Certain institutions had a social privilege that gave them a much greater distance from these issues, and it is easy now to reduce the distance to insignificance now. I can see how this reduction of difference is akin to a loss of a defence, or a reduction in protection, so when it comes after you I could see how it would be upsetting.

        I can see RMP as weak whistleblowing, and I’ve never shied from whistleblowing, but as per prior comments, I came from a working class town, and my language is a lot rougher than most people I know, just because that’s what I learned (I swear a lot). But I guess it also gives you the notion of a “job done well” and “not turning your back on your own” and if the things needed to be done, you did them. Why, because why not

        1. Pat, this is so interesting: “weak whistleblowing”. I think that’s one way of looking at RMP, although I don’t. But I think there’s a stronger whistleblowing practice around some of the patient intermediary or advocate services I’m looking at. That is, I think complex institutions really benefit from having third party organisations manage their users’ input. Arms length is a good thing here. And I think once a third party org is involved, like a whistleblowers’ org, then they can follow up where service users feel disempowered and stereotyped (and are often forgotten — thinking of Scott’s experiences above).

          But what you describe about tech fail in higher education, and the problems students then face, that’s a mess.

          Just had an interesting conversation here about our own institutional complaints instrument, that’s handled quite robustly in my experience. And I was asked: how come there aren’t more formal complaints about the parking?

          This really got me thinking about your GP receptionists question. Are there some elements of service or infrastructure that we just expect to be rubbish? So we don’t mention it, because it is what it is?

          1. I think RMP is weak whistleblowing as if it is the only open channel you have then where do you go? You can see in the UK the rise of medical negligence claims as a similar process to distance shortening.

            I don’t see not replying to emails as tech, it is a human failure.

            I think complaints department sums it up. On the MOOCs I’ve ran, we always get complaints and feedback – and to Kiplingise – I treat them just the same. But I’d never call the forum a complaints forum, as that basically shapes the conversation. What if you’ve got something like a suggestion, you’d not use a complaints forum.

            Expect to be rubbish – no, but roles which are gatekeepers and dealbreakers for the rest of the service

  5. Morning all. First up, I’m really grateful to hear from so many patients and health (or senior care) service users, and this has really got me thinking about my own patient experience.

    I was in cancer treatment for a year, and during that time I was involved in three minor “critical incident” experiences. One was a computer malfunction of a very big machine with me stuck inside it, alone in a room because that kind of technology requires its technicians to flee the scene when it’s on. So that was mentally very challenging.

    The other two were straightforward understaffing problems. One was reasonably frightening, involving an allergic reaction to a new medication, a risk I had mentioned beforehand, to make sure this known reaction to a particular drug was on someone’s mind when the transfusion began. I watched the incident unfold as though it wasn’t happening to me, and did a lot of thinking afterwards about what could have happened differently. I also thought hard about my relationship to the particular nurse who had not quite taken in what I was telling her, when I was telling her.

    In subsequent treatment encounters she and I talked quite a bit about her life, her training, her situation in the moment. Outwardly, I was probably just practising curiosity. Inwardly, I think I was trying to understand what had happened to me in that incident.

    The thing is, when institutions are critically underresourced or pursuing innovations that have negative consequences for service users, the Finance Director is never the one standing in front of you. It’s always someone else whose role is defined by their decisions, as yours is. Staff in any organisation are under pressure not to reveal the secrets of underresourcing to users. It’s “unprofessional”. So they (we) try hard to take the heat for things (they) we don’t control.

    And then as users, we have a vague sense of institutions, cultures, attitudes being the problem, but the institutional decision makers are nowhere to be found. So we shout and shout, and in review systems in particular the only grief we can really make stick is to the person closest to us.

    Listening to the recording of the veteran and the VA worker yesterday really made me think hard: what does it take to be generous to the person on the other end of the phone, who doesn’t have what you need, can’t meet the expectation that you are justified in holding. I wondered how come this veteran was able to do what he did, to see what he saw in that human pain that caused the woman to hang up on his call because she too was breaking down.

    So much to think through.

  6. I’m actually worn out on this subject for a while. Will be meeting the nurse who has been delaying an important diagnostic exam repeatedly requested by my doctor. Her reason stated on the phone was the doctor hadn’t mentioned that I was an actual cancer patient. Apparently, as a non-patient the request needs to be accompanied by the results from another test and she’s admitted she routinely throws “incomplete” requests in “dead file.” This is her procedure and I just don’t care if she’s tired because the last time I saw her she was asking my wife if I had a history of heart failure after being on the team that miss-diagnosed me for five weeks never once noticing the scar running end to end on my chest from my first open heart surgery. This question only came to her as I was being loaded on an air ambulance to the heart clinic in the city where I died, luckily, in their waiting room.

    Mostly I want her to look me in eye and explain herself.

    1. Oh my goodness, I understand this (I think). I have people I’d like to look me in the eye and explain something that happened. I’m truly so sorry for that worn out feeling. Thank you for coming to comment, Scott, I hope you’ll come again.

  7. Kate, fortunately I guess for me the incident of willfully ignoring a legitimate request singles one person and one abuse of policy out. Systems often break as a consequence of these one-at-a-time incidents but generally they are hidden in the complexity of the beast. In this case, others in the process themselves have noticed delays and disappearing requests. Though they have stated openly that my booking for myself is forbidden (You don’t call US, we call YOU”) I have been able to open the door a bit and I will report back on it to those who helped me out.

    The system itself still stinks and I’m not on a vendetta but this little victory will help me to shake some of the anger I have for being treated like dirt. It’s very hard to stay calm past being told my intruding in my own care is not allowed and I’m thinking my silence rather than an angry response highlighted how ridiculous telling a patient to mind there own business about their own business really is. Will be back when I get a result.

  8. I think that one can come at the ethics of commenting on care/learning experience from atleast threedirections and it is worth articulating them. First is from the rater or subject of the health or education experience. I don’t think that person necessariky needs to take into account the minutia of the medical or educational professional’s life, but they do need to ask if what they are expecting is fair – for me the answer is yes, to does s/he hear when I speak or write, can I make an appt in a timely manner, etc. but, no to do I like her hair do, does he succeed in breaking thriugh my studied boredom, does s/he respond to needs I feel but never express (for explanation, for reassurance, etc.). Of course there is more, but this is a three part comment so I will let others fill in blanks.
    Second is from the perspective of the professional being critiqued. Has he or she tried to make clear the limits of the role? Are they willing to explain again without getting ‘that’ voice, student or health client, you know what I mean? Does s/he try to learn from encounters that go badly – allergic reaction, student weeping.
    Third, from the perspective of the institution and public policy. I fear that we are in hard times for this is all the countries those responding live in. It isn’t fair to either individual at the pointy end of the encounters to expect them to totally overcome the institutional failures, but we can expect better of them. Many years ago when my daughter was undergoing cancer treatment in a pediatric unit, I was amazed at how well children and their parents were treated and how well the staff treated each other. Some examples: doctors self-corrected that voice and just explained again in different words, a third time if necessary, or more, staff did not ask parents to hold a struggling child for a painful or frightening treatment, if he child could not be talked into holding out the hand or whatever, staff did the holding – when I asked about the practice, they said because it was important that the parent not be one who hurt the child, but only a comforter. They encouraged children to give permission for treatment formally from 14, this included confidential talks with doctors without parents present because children protect parents and remain silent about some concerns. Parents were treated as part of the team, children were respected because it was their bodies that were being treated and they would have to live with the consequences of treatment. The unit social worker told me that this all is because child patients have parents to advocate for them and parents will go all out for their child.
    It is so difficult to self advocate in health care, indeed our diagnoses get in the way of our humanity. The model of that version of pediatrics would revolutionize health care and cost more money because it would need more time and hence more workers.

    I don’t know the answer to the conundrums this presents, but I do know that rating professors by hotness when so many of them are young and in some ways silly is not the answer. The questions push answers in particular directions
    I hope Scott finds a GP (yikes, such a simple request) and Pat gets the test. And that none of us requires our professionals to be HOT, only good enough on the day.

  9. Well I had my meeting with emergency room nurse in control of tests and just a case of an individual in a gate keeping that’s been there too long. Add that she’s situated within an arrangement of self-defining “professionals” unchallenged by any sense of duty–they are who they are and all that you will get here and that closes the conversation.

    I thank becalbury for the hope of a GP and also worry that hope is all there is left. All public systems here in Alberta seem incoherent, unplanned scatterings of individuals made ineffectual by an inability to agree on anything beyond what seems momentarily appropriate. The incident in hand has no history or depth, no reference point. Causality AND what actually presents are swept away by what is expected, needed or guessed at without reference to a second look. Its all either “Yes” or “No” based on one chance in one moment.

    Because of this, a person with chronic illness is forced to live a life of unresolved returns to the END to be pondered anew at each occurrence. There are no patterns or assurances ever or anywhere that life teaches anything. It’s all raw chance.

    What I find absurd is the enormous cost of training when the random application of intelligence is all that will emerge? Of course I’ll take the test to see if my cancer is back–they seem interested in me if I have cancer.

  10. Rebecca, Scott,

    On Friday two of us presented some questions and dilemmas in relation to patient stories at a forum of senior nurse leaders in the health district where I live, and where I was treated.

    We were asked careful, complicated questions about the ways in which this health district could use narrative research to understand more clearly how patients and staff bring their storied selves to the moment where they meet. The conundrum here is that nursing staff are still trained that it’s unprofessional to reveal the smallest thing about their own lives to patients. And listening to this I realised how smartly this raises a barrier that also proves harmful in direct and practical ways to us. Because if you are compelled to refuse your own story, then surely you must also refuse the story that is sitting in front of you, seeing only the medical condition in the moment, and the demands that can be made (or not) on the basis of that present/presenting state.

    I believe both as a patient and as a trained narrative practitioner that storying experience is critical to bringing history, depth and meaning to “the incident in hand”. I realised reading your comment, Scott, that I have incidents in hand that I haven’t found the language to explain even to myself. Listening to those nurse leaders on Friday it’s clear that they all do too, even more tightly bound than ours.

    Yes, yes, yes to the problem that we end up with: “incoherent, unplanned scatterings of individuals made ineffectual by an inability to agree on anything beyond what seems momentarily appropriate.” I’ve never seen it so well put. And the shattering impact on identity if the person with chronic illness then is forced to live that life of unresolved returns you describe. That’s it exactly.

    Thoughts with you both.

  11. Kate, this is a very good speech / article from Audrey Watters on affect http://hackeducation.com/2015/08/10/digpedlab/

    I think the facts are clear that current systems of care are designed to crush the emotional aspects of the patient. This is not by accident but a deliberate cost-cutting scheme to increase efficiency. Of course it can’t be said right out so the latest play is Patient Engagement where if you are polite and ask only appropriate questions you be given little favours and inconsequential supports in a blatantly in-genuine manner. If any of this felt real I might be convinced. But the initial insistence that I approach death with gratitude for those who refuse me feelings to suit policy has already turned me against them. We have become objects in conflict and nurture each others contempt.

    If it works out I need more care, the idea of approaching the ordeal as a robotic patient appeals. It’s always seemed a mixed favour when the Wizard of Oz granted the Tin Man’s request for a heart.

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