This YouTube video is fresh off my Facebook feed this morning from the APA. It features American Psychiatric Association (APA) President Jeffrey Lieberman, MD discussing the advantages of a so-called collaborative care model that brings psychiatrists into primary care clinics. I have critiqued this approach in the past and will continue to do so because it is basically managed care taken to its logical conclusion. As opposed to Dr. Lieberman's conclusion, the logical conclusion here is to simply take psychiatrists out of the picture all together.
A prototypical example of what I am talking about is the Diamond Project in Minnesota. It is an initiative by a consortium of managed care companies to use on of these models to monitor and treat depression in primary care clinics in the state of Minnesota. In this model, patients are screened and monitored using the PHQ-9 a rating scale for depressive symptoms. Their progress is monitored by a care manager and if there is insufficient progress as evidence by those rating scales, a psychiatrist is consulted about medication doses and other potential interventions. The model is described in this Wall Street Journal article. As is very typical of articles praising this approach it talks about the "shortage" of psychiatrists and how it will require adjustments. In the article for example, the author points out that there would no longer be "one-to-one" relationships. There are two major problems with this approach that seem to never be not considered.
The first is the standard of care. There are numerous definitions but the one most physicians would accept is care within a certain community that is the agreed upon standard provided by the same physician peers. In this case care provided by all psychiatrists for a specific condition like depression. There are professional guidelines for the care of depression and in the case of primary care guidelines for care provided by both family physicians and internal medicine specialists. One of the tenants of this care is that physicians generally base treatment of an assessment that they have done and documented. The only exception to that is an acceptable surrogate like a colleague in the same group covering a physician's patients when they are not available. That colleague generally has access to the documented assessment and plan to base decisions on. This is the central feature of all treatment provided by physicians and is also the basis for continuity of care. As such it also forms the basis of disciplinary action by state medical boards and malpractice claims for misdiagnosis and maltreatment. An example of disciplinary action based on this standard of care is inappropriate prescribing with no documented assessment or plan - a fairly common practice in the 1980s.
In all of my professional life, the standard of care has been my first and foremost consideration. It is basically a statement of accountability to a specific patient and that is what physicians are trained to be. Curiously it is not explicit in ethics literature and difficult to find in many state statutes regulating medical practice. That may be due to the entry of managed care and the introduction of business ethics rather than medical ethics. It also may be due in part to an old community mental health center practice of hiring psychiatrists essentially to refill prescriptions rather than assess patients. This is addressed from a malpractice perspective by Gutheil and Appelbaum in their discussion of malpractice considerations and how they changed with the advent of managed care:
"Managed care is one omnipresent constraint. Patients and clinicians must work together to fashion an appropriate treatment plan to take into account available resources and given the contingencies faced by the patient. If that plan-properly implemented-fails to prevent harm to the patient, the clinician should not face liability as a result." (p 164).
They go on to explain how ERISA - the Employee Retirement Income Security Act of 1974 indemnifies managed care companies and their reviewers from the same liability that individual physicians have. They cannot be sued for negligence and the resulting harm. So managed care can take risks without concern about penalties as opposed to physicians who are obliged to discuss risks with the patient. Managed care organizations can also implement broad programs like depression screening and treatment without a physician assessment and consider that their standard of care.
The second problem with the so-called collaborative care approach is that there is no evidence that it is effective on a large scale. I pointed out this criticism by a group of co-authors including one of the most frequently cited epidemiologists in the medical literature. That group has the common concern that a rating scale is a substitute for an actual diagnosis and everything that involves and given the recent FDA warning on citalopram.
Both of these concerns bring up an old word that nobody uses anymore - quality. It is customary today to use a blizzard of euphemisms instead. Words like "behavioral health", "managed care", accountable care organizations", "evidence-based", "cost-effective" and now "collaborative care". According to Orwell, the success of such political jargon and euphemism requires
"an uncritical or even unthinking audience. A 'reduced state of consciousness' as he put it, was 'favorable to political conformity'." (3 p. 124)
Dr. Lieberman uses a lot of that language in his video. The critics of psychiatry in the business community do the same. There appears to be a widespread uncritical acceptance of these euphemisms by politicians, businesses and even professional organizations.
An actual individualized psychiatric diagnosis and quality psychiatric care gets lost in that translation.
George Dawson, MD, DFAPA
1. Beck M. Getting mental health care at the doctor's office. Wall Street Journal September 24, 2013.
2. Gutheil TG, Appelbaum PS. Clinical Handbook Of Psychiatry And The Law. 3rd edition. Philadelphia: Lippincott Williams & Wilkens. 2000, p 164.
3. Nunberg G. Going Nucular: language, politics, and culture in confrontational times. Cambridge: Perseus Books Group, MA 2004.
4. American Psychiatric Association Principles of Medical Ethics with Annotations Espcially Applicable to Psychiatry. 2009 version.
Showing posts with label Jeffrey Lieberman MD. Show all posts
Showing posts with label Jeffrey Lieberman MD. Show all posts
Tuesday, October 22, 2013
Sunday, September 29, 2013
A Familiar Story - Another Shooting
The story is familiar and the media writes about it the same way. A mass shooting and the shooter has anger control problems, social problems, and finally probable symptoms of psychosis. The "ELF" considerations here were interesting. ELF is extremely low frequency as specified in this Wiki primer that covers most of the relevant facts. I grew up about 30 miles away from the original ELF site in Clam Lake, Wisconsin and there were plenty of conspiracy theories and environmental concerns right in the area at the time that surrounded this project including the effect of ELF on the residents.
The usual interviews with politicians about gun access and psychiatrists about whether or not violence can be predicted. It is a very familiar sequence of events. The White House is less vocal this time because I think everyone realizes that the government has no interest in solving the problem. You can click on mass homicide and mass shooting and see my previous posts on the matter for a more complete elaboration. There seems to be nothing new in the response to this mass shooting other than the question of security at American military installations.
My response is also the same and it is basically the following:
1. Mass homicide is a public health problem that can be addressed with public health interventions.
2. Violence and homicide prevention can occur even in the absence of firearm legislation.
3. Violence and homicide prevention does not require prediction of future events but the capacity to recognize markers of violence and psychiatric disorders and respond to them appropriately.
4. There need to be accessible speciality programs for the safe assessment and treatment of people with severe mental illnesses and aggressive behavior. That includes the assessment of threats since they are the precursors to the actual violence.
5. A standardized legal approach to the problem of the potentially dangerous person and whether or not mental illness is a factor is necessary.
6. A comprehensive policy that addresses the issues of progressively inadequate mental health funding is necessary to reverse these trends will provide the funding.
All of the above elements require a standardized approach to the care of the aggressive person and there are several clear reasons why that does not happen. The so-called mental health systems is fragmented and it has been for decades. It is basically designed to ration rather than provide care. That is a massive conflict of interest. Until that is acknowledged by the politicians and advocates nothing will be accomplished. It is very hard for politicians to acknowledge when they are backing a national agency that essentially endorses rationing and managed care. You can also compare my writing and suggested solutions to this problem to a recent "call to action" by American Psychiatric Association President Jeffrey A. Lieberman, MD.
How many "calls to action" does the APA need?
George Dawson, MD, DFAPA
The usual interviews with politicians about gun access and psychiatrists about whether or not violence can be predicted. It is a very familiar sequence of events. The White House is less vocal this time because I think everyone realizes that the government has no interest in solving the problem. You can click on mass homicide and mass shooting and see my previous posts on the matter for a more complete elaboration. There seems to be nothing new in the response to this mass shooting other than the question of security at American military installations.
My response is also the same and it is basically the following:
1. Mass homicide is a public health problem that can be addressed with public health interventions.
2. Violence and homicide prevention can occur even in the absence of firearm legislation.
3. Violence and homicide prevention does not require prediction of future events but the capacity to recognize markers of violence and psychiatric disorders and respond to them appropriately.
4. There need to be accessible speciality programs for the safe assessment and treatment of people with severe mental illnesses and aggressive behavior. That includes the assessment of threats since they are the precursors to the actual violence.
5. A standardized legal approach to the problem of the potentially dangerous person and whether or not mental illness is a factor is necessary.
6. A comprehensive policy that addresses the issues of progressively inadequate mental health funding is necessary to reverse these trends will provide the funding.
All of the above elements require a standardized approach to the care of the aggressive person and there are several clear reasons why that does not happen. The so-called mental health systems is fragmented and it has been for decades. It is basically designed to ration rather than provide care. That is a massive conflict of interest. Until that is acknowledged by the politicians and advocates nothing will be accomplished. It is very hard for politicians to acknowledge when they are backing a national agency that essentially endorses rationing and managed care. You can also compare my writing and suggested solutions to this problem to a recent "call to action" by American Psychiatric Association President Jeffrey A. Lieberman, MD.
How many "calls to action" does the APA need?
George Dawson, MD, DFAPA
Friday, August 30, 2013
Response to Dr. Lieberman on the Changing Times for Psychiatry
Jeffrey Lieberman, MD is the current President of the American Psychiatric Association (APA). He came out today with the first in a series of three statements on the changing profession of psychiatry. He starts out with an uneven historical recap of the first 200 years of the profession. I am probably sensitized to his use of Freud as an inflection point with my recent study of the philosophy of science. Freudian psychoanalysis and Adlerian psychology were Popper's original example of fields that did not meet logical criteria as a science. They were not falsifiable and therefore were unscientific. At the same time the neuropsychiatric movement based on phenomenology and neuroanatomy associated with German asylums is not mentioned. I suppose that a historical context is appropriate when considering all of the inflection points for the profession but let's face it - the first 150 of those 200 years are irrelevant to any scientifically based psychiatry and can be disregarded. He added a few paragraphs on the advent of psychopharmacology and the DSM as additional innovations and ends with his idea that the rising cost of health care and the pace of scientific discovery will be the two forces that shape the profession of psychiatry going forward.
My first problem with this statement is that there seems to be no role for psychiatrists or their professional organization in shaping the profession. We are there to be buffeted by rising costs and scientific discovery. Like most fields of medicine innovation has been driven by the clinicians and researchers in the field. When Len Stein, MD and his collaborators noticed that patients at the Mendota State Mental Health Institute were residing there in appalling conditions, they invented community psychiatry and community support teams and moved them out. There have been a long list of innovators in psychotherapy, psychopharmacology, neuroscience and in the general methods of psychiatry.
Taking Dr. Lieberman's points individually and starting with the rising cost of healthcare - what does that mean exactly and what does it mean in terms of psychiatric services? Thirty years ago some health plans covered unlimited psychotherapy. Many psychiatric trainees underwent psychoanalysis as part of their training and it was covered by health insurance. Today they would likely get a brief evaluation or a checklist and the offer of antidepressant medication if they scored high enough on a rating scale. If they were very fortunate they might see a crisis counselor for two or three sessions. How could this change in care possibly be related to rising costs? Psychiatric care has never been cheaper. The rising costs in medicine have to do with services that have pricing power and that never involves mental health. The real challenge here is a political one. It is very apparent that political systems and their partners in the business community will do everything possible to restrict access to psychiatric services - no matter how cheap they are. In the general scope of actual payments to providers there are no services that are more cost effective than psychiatry and until very recently that was essentially guaranteed by special billing codes that reimbursed psychiatry less.
The impact of rationing of psychiatric services by managed care companies, state and federal governments go beyond the purely economic. When psychiatric services are easily rationed, evidence based services that are more expensive like Assertive Community Treatment can simply be made a non covered service. There are few functional detoxification facilities for people with severe drug and alcohol problems. Most people are sent home from an emergency department with medications to "self detox" or sent to a county run facility with no medical services. They are readmitted when that fails or when they develop complications that require intensive care such as seizures or delirium tremens. The majority have no chance to achieve sobriety from outpatient detox of significant addictions. The hospital evaluation and treatment of severe disorders that often take weeks or months to assess and treat are restricted to a few days. The actual admission and discharge decisions from hospitals and treatment centers are no longer medical decisions but they are based on arbitrary guidelines made up by business organizations. Entire hospital and clinic environments are run by administrators with no psychiatric training. There are actually situations where administrators seem to believe that they can design treatment programs that target behavioral problems when they are not clinicians. The "rising cost of health care" rhetoric is frequently used to rationalize a nationwide approach to mental illness that is totally nonfunctional. This has been the result of a series of "reforms" that basically turned the field over to the managed care industry.
Psychiatric research and the neuroscience research that applies to psychiatry is vast. When physicians are trained we are all taught to value ongoing education. At some point the education of physicians also became a political football. There are initiatives to teach physicians how to treat pain. A decade later there are initiatives to retrain physicians who are prescribing too many opioids - despite the fact that the original initiative had a goal of appropriate assessment and treatment. Specialty boards and the oversight board unilaterally decided that the public wanted board certification to be time limited. They came up with a Maintenance of Certification (MOC) procedure despite the lack of evidence that it was necessary. That allowed several states to consider tying medical licensing to these costly and unnecessary exams. The best way to educate physicians is an active collaboration at both the clinical and basic science levels like many specialty boards were doing at the time of the new idea about MOC.
These are the dimensions that shape my world as a psychiatrist every day. They have been responsible for the deterioration of the practice environment and decreased quality of care across most treatment settings. Contrary to Dr. Lieberman's points there has been no reform and there certainly is no enlightenment. Despite all of the research and expanding knowledge clinical psychiatry is in the Dark Ages as external forces suppress psychiatrists and limit creativity and innovation.
George Dawson, MD, DFAPA
Jeffrey Lieberman, MD. Change, Challenge, and Opportunity: Psychiatry in Age of Reform and Enlightenment. Psychiatric News August 29, 2013
My first problem with this statement is that there seems to be no role for psychiatrists or their professional organization in shaping the profession. We are there to be buffeted by rising costs and scientific discovery. Like most fields of medicine innovation has been driven by the clinicians and researchers in the field. When Len Stein, MD and his collaborators noticed that patients at the Mendota State Mental Health Institute were residing there in appalling conditions, they invented community psychiatry and community support teams and moved them out. There have been a long list of innovators in psychotherapy, psychopharmacology, neuroscience and in the general methods of psychiatry.
Taking Dr. Lieberman's points individually and starting with the rising cost of healthcare - what does that mean exactly and what does it mean in terms of psychiatric services? Thirty years ago some health plans covered unlimited psychotherapy. Many psychiatric trainees underwent psychoanalysis as part of their training and it was covered by health insurance. Today they would likely get a brief evaluation or a checklist and the offer of antidepressant medication if they scored high enough on a rating scale. If they were very fortunate they might see a crisis counselor for two or three sessions. How could this change in care possibly be related to rising costs? Psychiatric care has never been cheaper. The rising costs in medicine have to do with services that have pricing power and that never involves mental health. The real challenge here is a political one. It is very apparent that political systems and their partners in the business community will do everything possible to restrict access to psychiatric services - no matter how cheap they are. In the general scope of actual payments to providers there are no services that are more cost effective than psychiatry and until very recently that was essentially guaranteed by special billing codes that reimbursed psychiatry less.
The impact of rationing of psychiatric services by managed care companies, state and federal governments go beyond the purely economic. When psychiatric services are easily rationed, evidence based services that are more expensive like Assertive Community Treatment can simply be made a non covered service. There are few functional detoxification facilities for people with severe drug and alcohol problems. Most people are sent home from an emergency department with medications to "self detox" or sent to a county run facility with no medical services. They are readmitted when that fails or when they develop complications that require intensive care such as seizures or delirium tremens. The majority have no chance to achieve sobriety from outpatient detox of significant addictions. The hospital evaluation and treatment of severe disorders that often take weeks or months to assess and treat are restricted to a few days. The actual admission and discharge decisions from hospitals and treatment centers are no longer medical decisions but they are based on arbitrary guidelines made up by business organizations. Entire hospital and clinic environments are run by administrators with no psychiatric training. There are actually situations where administrators seem to believe that they can design treatment programs that target behavioral problems when they are not clinicians. The "rising cost of health care" rhetoric is frequently used to rationalize a nationwide approach to mental illness that is totally nonfunctional. This has been the result of a series of "reforms" that basically turned the field over to the managed care industry.
Psychiatric research and the neuroscience research that applies to psychiatry is vast. When physicians are trained we are all taught to value ongoing education. At some point the education of physicians also became a political football. There are initiatives to teach physicians how to treat pain. A decade later there are initiatives to retrain physicians who are prescribing too many opioids - despite the fact that the original initiative had a goal of appropriate assessment and treatment. Specialty boards and the oversight board unilaterally decided that the public wanted board certification to be time limited. They came up with a Maintenance of Certification (MOC) procedure despite the lack of evidence that it was necessary. That allowed several states to consider tying medical licensing to these costly and unnecessary exams. The best way to educate physicians is an active collaboration at both the clinical and basic science levels like many specialty boards were doing at the time of the new idea about MOC.
These are the dimensions that shape my world as a psychiatrist every day. They have been responsible for the deterioration of the practice environment and decreased quality of care across most treatment settings. Contrary to Dr. Lieberman's points there has been no reform and there certainly is no enlightenment. Despite all of the research and expanding knowledge clinical psychiatry is in the Dark Ages as external forces suppress psychiatrists and limit creativity and innovation.
George Dawson, MD, DFAPA
Jeffrey Lieberman, MD. Change, Challenge, and Opportunity: Psychiatry in Age of Reform and Enlightenment. Psychiatric News August 29, 2013
Thursday, May 30, 2013
Brooks on Psychiatrists As "Heroes of Uncertainty"
Well I suppose it is slightly better than the usual characterizations that we see in the New York Times, but David Brooks recent column on the "improvisation, knowledge and artistry" involved in psychiatry is little more than damning with faint praise. His flaws include using the term "technical expertise" and comparing psychiatry to "physics and biology". Psychiatry is certainly comparable to biology but not to physics. And what is it about psychiatry that is unscientific? The idea that psychiatry seeks to legitimize itself by appearing to be scientific is a popular antipsychiatry theme. It is probably why many authors seek to equate psychiatry with the DSM. The science of psychiatry is out there in many technical journals that are scarcely ever mentioned in the public commentary about psychiatry. The idea that the science of psychiatry is collapsed into a modest (at best) diagnostic manual is a convenient way to deny that fact and portray psychiatrists as unscientific and perhaps not very much like physicians either.
Brooks characterization of the DSM shows a continued lack of understanding of this manual by every journalist who writes about it. There is practically no psychiatrist I know of who considers it to be authoritative. Very few psychiatrists actually go about their diagnostic business by reading through DSM criteria. That activity would be limited to novices and medical students. It is well known that only a fraction of the diagnoses listed are ever used in clinical practice. After familiarizing themselves with the major changes, few psychiatrists will every open it again. Like most physicians, psychiatrists are looking for patterns of illness that are based more on their clinical experience than criteria listed in a manual. The idea that this text has "an impressive aura of scientific authority" is certainly consistent with Brook's thesis, but that is not what a psychiatrist experiences when looking at it. Despite all of the concern about the public impact - psychiatrists are the target audience here. Psychiatrists are much more aware of the limitations of the approach than the media critics who write about it. I guess a lay person might be impressed, but I never met a psychiatrist who was.
Brooks is also confused about the nature of the DSM when he states that it contains "a vast body of technical knowledge that will allow her (your psychiatrist) to solve your problems". That vast body of technical knowledge is firmly outside of the DSM and it is in the form of training and ongoing education of a psychiatrist. That technical knowledge is contained in a vast literature, much of it written by psychiatrists. It is the reason that ongoing training and education of physicians is a career long commitment. In the general scope of things, the DSM would contribute a percentage point or two at most to that body of knowledge.
There is the associated question about whether physicians are scientists or not. I have seen Kandel himself interviewed about this issue and he states quite definitely that they are not. That is quite different from suggesting that physicians are unscientific. There are certainly not many physicians who are performing scientific experiments and publishing papers. I suppose that you have to do that to be a professional scientist. On the other hand, physicians are certainly accountable for learning immense amounts of of scientific principles and data that can be applied in clinical situations and used in critical thinking about patients and teaching it to successive generations of physicians.. I teach Dr. Kandel's plasticity concept and how it applies to addictions in about 30 lectures a year. Reducing scientific knowledge to "artistry" is really inconsistent with "technical expertise". There really is no art in medicine. The most technically competent doctors know the science, have seen more patterns of illness and can recognize those patterns. They can apply that knowledge to patient care. In complex medical (and psychiatric) care, a special plan can be designed for each individual patient and most aspects of that plan are rooted in science.
This essay strains under the weight of needing to place psychiatry outside of the scope of science and mainstream medicine. My study of psychiatry finds it in neither of those locations. There is a reason that psychiatrists need to go to medical school. The cross section of basic science and clinical science that all physicians are exposed to is necessary to be a psychiatrist. Using Brooks reasoning, I suppose he could say that this is just an effort to "legitimize" psychiatry by making it seem like it is on scientific par with the other fields of medicine. When I am face to face with a severely ill patient who has liver disease, heart disease, diabetes, alcoholism and a refractory psychiatric disorder - the science involved is much more than a political exercise.
Like every other branch of medicine, psychiatry is an amalgam of the clinical and basic sciences. Biology especially neuroscience but also the anatomy and physiology of the human body is the central focus. I will give Brooks partial credit when he writes about the DSM. Unlike many of his colleagues at the NY Times - he does not refer to it as a "Bible". When it comes to the issue of whether I am a scientist or not, I certainly realize that I am no Eric Kandel. But I also know that I am not rolling the dice or taking a leap of faith. I am doctor seeing people, trying to understand their unique set of problems, and applying medical science to help them get better.
George Dawson, MD. DFAPA
David Brooks. Heroes of Uncertainty. NYTimes May 27, 2013.
Brooks characterization of the DSM shows a continued lack of understanding of this manual by every journalist who writes about it. There is practically no psychiatrist I know of who considers it to be authoritative. Very few psychiatrists actually go about their diagnostic business by reading through DSM criteria. That activity would be limited to novices and medical students. It is well known that only a fraction of the diagnoses listed are ever used in clinical practice. After familiarizing themselves with the major changes, few psychiatrists will every open it again. Like most physicians, psychiatrists are looking for patterns of illness that are based more on their clinical experience than criteria listed in a manual. The idea that this text has "an impressive aura of scientific authority" is certainly consistent with Brook's thesis, but that is not what a psychiatrist experiences when looking at it. Despite all of the concern about the public impact - psychiatrists are the target audience here. Psychiatrists are much more aware of the limitations of the approach than the media critics who write about it. I guess a lay person might be impressed, but I never met a psychiatrist who was.
Brooks is also confused about the nature of the DSM when he states that it contains "a vast body of technical knowledge that will allow her (your psychiatrist) to solve your problems". That vast body of technical knowledge is firmly outside of the DSM and it is in the form of training and ongoing education of a psychiatrist. That technical knowledge is contained in a vast literature, much of it written by psychiatrists. It is the reason that ongoing training and education of physicians is a career long commitment. In the general scope of things, the DSM would contribute a percentage point or two at most to that body of knowledge.
There is the associated question about whether physicians are scientists or not. I have seen Kandel himself interviewed about this issue and he states quite definitely that they are not. That is quite different from suggesting that physicians are unscientific. There are certainly not many physicians who are performing scientific experiments and publishing papers. I suppose that you have to do that to be a professional scientist. On the other hand, physicians are certainly accountable for learning immense amounts of of scientific principles and data that can be applied in clinical situations and used in critical thinking about patients and teaching it to successive generations of physicians.. I teach Dr. Kandel's plasticity concept and how it applies to addictions in about 30 lectures a year. Reducing scientific knowledge to "artistry" is really inconsistent with "technical expertise". There really is no art in medicine. The most technically competent doctors know the science, have seen more patterns of illness and can recognize those patterns. They can apply that knowledge to patient care. In complex medical (and psychiatric) care, a special plan can be designed for each individual patient and most aspects of that plan are rooted in science.
This essay strains under the weight of needing to place psychiatry outside of the scope of science and mainstream medicine. My study of psychiatry finds it in neither of those locations. There is a reason that psychiatrists need to go to medical school. The cross section of basic science and clinical science that all physicians are exposed to is necessary to be a psychiatrist. Using Brooks reasoning, I suppose he could say that this is just an effort to "legitimize" psychiatry by making it seem like it is on scientific par with the other fields of medicine. When I am face to face with a severely ill patient who has liver disease, heart disease, diabetes, alcoholism and a refractory psychiatric disorder - the science involved is much more than a political exercise.
Like every other branch of medicine, psychiatry is an amalgam of the clinical and basic sciences. Biology especially neuroscience but also the anatomy and physiology of the human body is the central focus. I will give Brooks partial credit when he writes about the DSM. Unlike many of his colleagues at the NY Times - he does not refer to it as a "Bible". When it comes to the issue of whether I am a scientist or not, I certainly realize that I am no Eric Kandel. But I also know that I am not rolling the dice or taking a leap of faith. I am doctor seeing people, trying to understand their unique set of problems, and applying medical science to help them get better.
George Dawson, MD. DFAPA
David Brooks. Heroes of Uncertainty. NYTimes May 27, 2013.
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