White House officials can be oddly candid in talking to their liberal
friends at the New Yorker magazine. That’s where an unnamed official in
2011 boasted of “leading from behind,” and where last year President Obama
dismissed Islamic State as a terrorist “jayvee team.” Now the U.S. Vice
President has revealed the Administration line on human rights in
China.
In the April 6 issue, Joe Biden recounts meeting Xi Jinping
months before his 2012 ascent to be China’s supreme leader. Mr. Xi
asked him why the U.S. put “so much emphasis on human rights.” The right
answer is simple: No government has the right to deny its citizens
basic freedoms, and those that do tend also to threaten peace overseas,
so U.S. support for human rights is a matter of values and interests.
Instead,
Mr. Biden downplayed U.S. human-rights rhetoric as little more than
political posturing. “No president of the United States could represent
the United States were he not committed to human rights,” he told Mr.
Xi. “President Barack Obama would not be able to stay in power if he did
not speak of it. So look at it as a political imperative.” Then Mr.
Biden assured China’s leader: “It doesn’t make us better or worse. It’s
who we are. You make your decisions. We’ll make ours.” [not the WSJ's emphasis.]
Mr. Xi took the advice. Since taking office he has detained more
than 1,000 political prisoners, from anticorruption activist Xu Zhiyong
to lawyer Pu Zhiqiang and journalist Gao Yu. He has cracked down on Uighurs in Xinjiang, banning more Muslim practices and jailing scholar-activist Ilham Tohti for life. Anti-Christian repression and Internet controls are tightening. Nobel Peace laureate Liu Xiaobo remains in prison, his wife Liu Xia
under illegal house arrest for the fifth year. Lawyer Gao Zhisheng left
prison in August but is blocked from receiving medical care overseas.
Hong Kong, China’s most liberal city, is losing its press freedom and
political autonomy.
Amid all of this Mr. Xi and his government have faced little challenge from Washington. That is consistent with Hillary Clinton’s
2009 statement that human rights can’t be allowed to “interfere” with
diplomacy on issues such as the economy and the environment. Mr. Obama
tried walking that back months later, telling the United Nations that
democracy and human rights aren’t “afterthoughts.” But his
Administration’s record—and now Mr. Biden’s testimony—prove otherwise.
JAMA Surg. Published online March 11, 2015. doi:10.1001/jamasurg.2014.2911.
On Thursday mornings, our operating room management committee meets
to handle items large and small. Most of our discussions focus on
block-time allocation, purchasing decisions, and alike. However, too
often we talk about behavioral issues, particularly the now
well-characterized disruptive physician.
We have all seen it or been there before. A physician acts out in the
operating room with shouting or biting sarcasm, intimidating colleagues
and staff and impeding them from functioning at a high level. The most
debilitating perpetrators of this behavior are repeat customers who
engender such fear and uncertainty in all who contact them that the
morale of the nursing staff and anesthesiologists is undermined, work
becomes an unbearable chore, and performance suffers.
When one engages a difficult physician on his or her behavior, the
physician responds in characteristic fashion. He or she defends his or
her actions as patient advocacy, pointing out the shortcomings of the
scrub nurse or instruments and showing limited, if any, remorse. He or
she argues that such civil disobedience is the only way to enact change.
In truth, disruptive physicians’ actions are often admired by a sizable
minority of their colleagues as the only way to articulate real
frustrations of working in today’s highly complex hospital. In extreme
situations, these physicians become folk heroes to younger physicians
who envy their fortitude in confronting the power of the bureaucracy.
A few days after a recent outburst by a particularly unpleasant and
repeat offender, I was enjoying my daily interval on the stationary
bicycle at my gym. My thoughts were wandering to a broad range of
topics. I spent some time considering what really drives this
nonproductive behavior and how otherwise valuable physicians could be
channeled successfully into a more collegial state. As in the past, I
was long on theory but short on conviction that it would make a
difference.
After my workout as I prepared to shower, I received an urgent email.
A patient I was consulting for upper extremity embolization had
developed confusion and possible cerebral emboli despite full
anticoagulation. I responded that I was on my way to see her and
suggested a few diagnostic tests and consultations.
As I typed my message, a custodial employee of the gym reminded me
that no cellular telephones were allowed in the locker room. I pointed
out that I was not using my cellular telephone but rather an email
function and I was not offending anyone by talking. He again pointed out
that cellular telephones were not allowed under any circumstances. As I
argued back, “I am a physician and this is an emergency.” My voice got
louder and I became confrontational. I told him to call the manager.
Another member next to me said quietly that the reason for the cellular
telephone ban was the photographic potential of the devices and that I
could have simply moved to the reception area and used the telephone any
way I wished.
I felt like the fool I was. I trudged off to the showers feeling, as
in the Texas homily, lower than a snake’s belly. After toweling off, I
approached the employee and apologized for my behavior and for making
his job more difficult. I told him he had handled the situation far
better than me and I admired his restraint.
The lessons were stark and undeniable. Like my disruptive colleagues,
I had justified my boorish behavior with patient care. I had assumed my
need to break the rules far outweighed the reasonable and rational
policy of the establishment; after all, I was important and people
depended on me. Worse yet, I felt empowered to take out my frustration,
enhanced by my worry about the patient, on someone unlikely to retaliate
against me for fear of job loss.
I have come to realize that irrespective of disposition, when the
setting is right, we are all potentially disruptive. The only questions
are how frequent and how severe. Even more importantly, from a
prognostic perspective, can we share the common drivers of these
behaviors and develop insights that will lead to avoidance?
The most common approaches used today are only moderately effective.
As in many other institutions, when physicians are deemed by their peers
to have violated a carefully defined code of conduct, they are advised
to apologize to any offended personnel. In many instances, these
apologies are sincere and are, in fact, appreciated by all.
Unfortunately, on occasion, the interaction is viewed as a forced
function and the behavior is soon repeated albeit in a different nursing
unit or operating room.
When such failures occur, persistently disruptive physicians are
referred to our physician well-being committee. Through a highly
confidential process, efforts are made to explore the potential causes
for the behavior and acquaint the referred physician with the
consequences of their actions on hospital function. Often, behavioral
contracts are drawn up to precisely outline the individual’s issues and
subsequent medical staff penalties if further violations occur.
That said, as well intentioned and psychologically sound as these
programs are, there remains a hard core of repeat offenders. Despite the
heightened stress and ill will engendered by disruptive physicians’
behavior, they simply cannot interact in other than confrontational
fashion when frustrated by real or imagined shortcomings in the
environment.
Based on nearly 20 years of physician management experience, it is my
belief that in these few physicians, such behaviors are hard wired and
fairly resistant to traditional counseling. An unfortunate end game is
termination from a medical staff if the hostile working environment
created by their outbursts is viewed as a liability threat by the
institution. Such actions are always painful and bring no satisfaction
to anyone involved. These high-stakes dramas, often involving critical
institutional players on both sides, are played out behind closed doors.
Few people are privy to the details of either the infraction or the
attempts at remediation. Misunderstandings in the staff are common.
I suggest that an underused remedy is more intense peer pressure
through continued education of those colleagues who might silently
support these outbursts without fully realizing the consequences. This
would begin by treating these incidents in the same way that we do other
significant adverse events that occur in our hospitals. In confidential
but interdisciplinary sessions, the genesis, nature, and consequences
of the interaction could be explored openly. If indeed the inciting
event was judged to be an important patient care issue, the problem
could be identified and addressed yet clearly separated from the
counterproductive interaction that followed. In addition to the
deterrence provided by the more public airing of the incidents, the
tenuous linkage between abusive behavior and patient protection could be
severed. It is this linkage that provides any superficial legitimacy to
the outbursts.
Through this process, peer pressure would be increased and provide a
greater impetus for self-control and more productive interactions.
Importantly, with such a direct and full examination of both the
character and costs of poor conduct, whatever support exists for such
behaviors within the medical staff would be diminished.
Bruce Gewertz, MD, Cedars-Sinai Health System
Published Online: March 11, 2015. doi:10.1001/jamasurg.2014.2911. Conflict of Interest Disclosures: None reported.
The
Obama
administration’s troubling flirtation with another mortgage
meltdown took an unsettling turn on Tuesday with Federal Housing Finance
Agency Director
Mel Watt
’s testimony before the House Financial Services Committee.
Mr.
Watt told the committee that, having received “feedback from
stakeholders,” he expects to release by the end of March new guidance on
the “guarantee fee” charged by
Fannie Mae
and
Freddie Mac
to cover the credit risk on loans the federal mortgage agencies guarantee.
Here
we go again. In the Obama administration, new guidance on housing
policy invariably means lowering standards to get mortgages into the
hands of people who may not be able to afford them.
Earlier this
month, President Obama announced that the Federal Housing
Administration (FHA) will begin lowering annual mortgage-insurance
premiums “to make mortgages more affordable and accessible.” While that
sounds good in the abstract, the decision is a bad one with serious
consequences for the housing market.
Government programs to make
mortgages more widely available to low- and moderate-income families
have consistently offered overleveraged, high-risk loans that set up too
many homeowners to fail. In the long run-up to the 2008 financial
crisis, for example, federal mortgage agencies and their regulators
cajoled and wheedled private lenders to loosen credit standards. They
have been doing so again. When the next housing crash arrives, private
lenders will be blamed—and homeowners and taxpayers will once again pay
dearly.
Lowering annual mortgage-insurance premiums is part of a
new affordable-lending effort by the Obama administration. More
specifically, it is the latest salvo in a price war between two
government mortgage giants to meet government mandates.
Fannie
Mae fired the first shot in December when it relaunched the 30-year, 97%
loan-to-value, or LTV, mortgage (a type of loan that was suspended in
2013). Fannie revived these 3% down-payment mortgages at the behest of
its federal regulator, the Federal Housing Finance Agency (FHFA)—which
has run Fannie Mae and Freddie Mac since 2008, when both
government-sponsored enterprises (GSEs) went belly up and were put into
conservatorship. The FHA’s mortgage-premium price rollback was a
counteroffensive.
Déjà vu: Fannie launched its first price war
against the FHA in 1994 by introducing the 30-year, 3% down-payment
mortgage. It did so at the behest of its then-regulator, the Department
of Housing and Urban Development. This and other actions led HUD in 2004
to credit Fannie Mae’s “substantial part in the ‘revolution’ ” in
“affordable lending” to “historically underserved households.”
Fannie’s
goal in 1994 and today is to take market share from the FHA, the main
competitor for loans it and Freddie Mac need to meet mandates set by
Congress since 1992 to increase loans to low- and moderate-income
homeowners. The weapons in this war are familiar—lower pricing and
progressively looser credit as competing federal agencies fight over
existing high-risk lending and seek to expand such lending.
Mortgage
price wars between government agencies are particularly dangerous,
since access to low-cost capital and minimal capital requirements gives
them the ability to continue for many years—all at great risk to the
taxpayers. Government agencies also charge low-risk consumers more than
necessary to cover the risk of default, using the overage to lower fees
on loans to high-risk consumers.
Starting in 2009 the FHFA
released annual studies documenting the widespread nature of these
cross-subsidies. The reports showed that low down payment, 30-year loans
to individuals with low FICO scores were consistently subsidized by
less-risky loans.
Unfortunately, special interests such as the
National Association of Realtors—always eager to sell more houses and
reap the commissions—and the left-leaning Urban Institute were
cheerleaders for loose credit. In 1997, for example, HUD commissioned
the Urban Institute to study Fannie and Freddie’s single-family
underwriting standards. The Urban Institute’s 1999 report found that
“the GSEs’ guidelines, designed to identify creditworthy applicants, are
more likely to disqualify borrowers with low incomes, limited wealth,
and poor credit histories; applicants with these characteristics are
disproportionately minorities.” By 2000 Fannie and Freddie did away with
down payments and raised debt-to-income ratios. HUD encouraged them to
more aggressively enter the subprime market, and the GSEs decided to
re-enter the “liar loan” (low doc or no doc) market, partly in a desire
to meet higher HUD low- and moderate-income lending mandates.
On
Jan. 6, the Urban Institute announced in a blog post: “FHA: Time to stop
overcharging today’s borrowers for yesterday’s mistakes.” The institute
endorsed an immediate cut of 0.40% in mortgage-insurance premiums
charged by the FHA. But once the agency cuts premiums, Fannie and
Freddie will inevitably reduce the guarantee fees charged to cover the
credit risk on the loans they guarantee.
Now the other shoe appears poised to drop, given Mr. Watt’s promise on Tuesday to issue new guidance on guarantee fees.
This
is happening despite Congress’s 2011 mandate that Fannie’s regulator
adjust the prices of mortgages and guarantee fees to make sure they
reflect the actual risk of loss—that is, to eliminate dangerous and
distortive pricing by the two GSEs. Ed DeMarco, acting director of the
FHFA since March 2009, worked hard to do so but left office in January
2014. Mr. Watt, his successor, suspended
Mr. DeMarc
o’s efforts to comply with Congress’s mandate. Now that Fannie
will once again offer heavily subsidized 3%-down mortgages, massive new
cross-subsidies will return, and the congressional mandate will be
ignored.
The law stipulates that the FHA maintain a
loss-absorbing capital buffer equal to 2% of the value of its
outstanding mortgages. The agency obtains this capital from profits
earned on mortgages and future premiums. It hasn’t met its capital
obligation since 2009 and will not reach compliance until the fall of
2016, according to the FHA’s latest actuarial report. But if the economy
runs into another rough patch, this projection will go out the window.
Congress
should put an end to this price war before it does real damage to the
economy. It should terminate the ill-conceived GSE affordable-housing
mandates and impose strong capital standards on the FHA that can’t be
ignored as they have been for five years and counting.
Mr. Pinto,
former chief credit officer of Fannie Mae, is co-director and
chief risk officer of the International Center on Housing Risk at the
American Enterprise Institute.