Tuesday, July 5, 2016

The Upside of Down: Chapter 4

ACCIDENTS, MISTAKES, FAILURES, AND DISASTERS: What the Hospital System Can Teach Us about the Mistakes We Make

A.K.A. I Had A Mental List Of Infuriating Things I Thought I'd See In This Book And This Wasn't On It

"Narrative nonfiction" is a literary term that's been thrown around a lot over the past decade or so. It's usually used interchangeably with memoir, which is about half-accurate. Basically, narrative nonfiction is a true-to-life account that contains conventions associated with short stories and novels, such as dialogue and the author's personal perspectives. This encompasses memoir and autobiography as well as non-objective forms of journalism such as "new journalism" (read: What hack writers call gonzo journalism so that their work doesn't come across as warmed over Hunter Thompson).

There was a major boom in narrative nonfiction a few years ago, with a number of unknown writers becoming overnight celebrities on the basis of their Incredible True Stories. The trend has since cooled a bit on both the supply and demand ends (probably due to a flood of unmarketable "misery memoirs" along with the exposure of several high-profile writers as frauds), but it's still probably the easiest type of manuscript to get past the gatekeepers. The "true story" has an appeal that can overcome mediocre writing, a phenomenon that has greatly benefited failed-novelist-turned-literary fraud James Frey. I'd argue narrative nonfiction enjoys the lowest standards in the business, as it is expected to have neither the hard factual basis of other forms of non-fiction nor the skill and literary sensibility of the novel.

Why would I preface a McArdle post like this? I don't know, just seemed like it might be relevant.

It is here, in Chapter 4 or her book on failure, that McArdle decides that she should define the term "failure." That kind of thing is obligatory in business books, but the fact that I hadn't seen it after nearly a hundred pages had given me hopes of dodging that particular bullet. She settles on "a mistake without a safety net."

The fail-safes aren't failing safely any more. Suddenly, something has gone terribly wrong, and worse, if someone had only done things differently - better - it could have been prevented.
The rest of the chapter is about Megan McArdle's mother getting appendicitis. It seems like McArdle's attempt at emotional writing, and the tonal shift is as jarring as a sucker punch.

I'm kind of at a loss as to how to cover this chapter, since it is such a radical departure, so I'll go with what I did at the end of Chapter 3 and analyze it according to its adherence to both the stated and unstated thesis. To wit:
  • Stated: How to manage risk through proper procedure.
  • Unstated: Why Megan McArdle is smarter than everyone and therefore deserves to be successful.
Now who wants some quotes?

Because I cover the health-care system, I knew how to look up the relevant studies...

Sure you do. For the record, that "hypothetical, not a statistic" bit from the last post was drawn from McArdle's "coverage" of health care. There's an extended rundown of the aftermath here, which I'd recommend reading just to see how Megan McArdle actually deals with being wrong. Hint: She doesn't treat it as a learning experience.

Following this is a subhead titled "My First Mistake." Holy crap, is McArdle about to admit to being wrong?

"I'm really sick," [Mom] said. "I've never been this sick."
"Do you want me to come take you to the emergency room?" I asked anxiously. The column was due that day. On the other hand, well, Mom.
"No," she said weakly. "I just got to sleep. I didn't sleep all night. I have terrible, terrible pains in my stomach."
"Are you sure?" I asked.
"Yes," she said. "I just want to sleep."
"Okay, I love you," I said, and hung up the phone. That was my first mistake.

That's quite an admission. I'd take it a little more seriously if McArdle didn't spend the rest of the chapter pointing out that everyone else was making mistakes that she spotted easily.

Two other things to note about this passage. First, there's an endnote that I initially missed. It connects to a paragraph-length explanation that this chapter is based on "live observations and very fresh memories." I assume that this was included to ward off any smartass who'd studied up on the fallibility of memory and knew that people tend to misremember things in ways that flatter them and that there's reason to doubt people's recollections even (or especially) when they claim to have nearly perfect recall. But that would be cynical, and we're not about cynicism here, are we?

Second, and here's a little behind the scenes: I was walking down the street when I first read this, and if it wasn't a public place then this is where I would have erupted into obscenity. In six lines of dialogue, McArdle tags two interrogatory sentences with "asked" and drops in two adverbs. Minor points? Perhaps to the reader. But every time I send off a manuscript, I have to double check it to make sure that I didn't use tags like "asked" or "answered" or use too many adverbs with tags. If either flub shows up in the first fifty pages, my efforts are going to end up in the circular filing cabinet. As I've said many times before: In the publishing biz, you have to be a professional to make rookie mistakes.

The next few pages are dedicated to something McArdle calls the "spell-check factor," which is something to do with how fail-safes can make a system less safe because no one's prepared for failure (and please remember this, it's going to become important later). And then we're back to the hospital, and...would it shock any of you to learn that McArdle talks about herself a lot in here? This section is ostensibly about how complex systems get all jammed up, but in practice it seems more like McArdle, having established herself as a fake expert in one field (economics) is now trying to set up bona fides in another (medicine). And why not? If David Brooks can get invited to speak as an expert in neuroscience on the basis of a terrible science-flavored novel, then clearly everything is on the table.

You want an example? Here's an example:

The surgical drain they used to evacuate her largest abscess became blocked soon after it was put in and stopped draining. This was probably because no one was following the standard procedure of flushing it once a day with saline...My sister and I pointed out the conspicuous lack of drainage to several people, including both her day and night nurses, but they all insisted it was fine.

Of course, it's possible that, in a busy Washington, D.C. hospital, that numerous people on staff made very basic mistakes. It happens a lot, so much that it's hard to get accurate numbers on how often. Professionals are still human, after all. Then again, it's also possible that McArdle was one of those people hovering over the nurses, saying things like "You didn't flush that line right. Look, I cover health care for a living, okay? I know how to look up the relevant studies. I think I know what I'm talking about" until the staff start to discuss the ethical implications in spiking her drink with a massive dose of midazolam and letting her sleep it off somewhere off site. I'll leave it up to the reader to decide which is more likely.

The next section is about categories of failure and is back on point. Well, somewhat on point - it still has passages like this:

There's something autocratic and distasteful about quasi-normative error. And yet, in the context of a surgery ward, when keeping people alive is often a matter of doing everything almost exactly right, it makes a sort of sense. The legendary rock band Van Halen used to demand that all concert venues provide them a bowl of M&Ms with all the brown ones picked out...

No, I didn't skip a line break.

So it's obvious how this chapter ties in to the unstated thesis, but what about the stated thesis? That comes in the last two paragraphs:

Over the years, companies and professions develop standards to protect themselves (and others) from bad outcomes that only happen some of the time. A rogue trader usually can't destroy the company with a judgment error unless he has also circumvented the internal controls designed to prevent him from taking on too much risk...People who commit normative errors are generally too focused on the result, and not enough on the process.
This isn't a surprise, as I've heard McArdle say this before. It's a lesson she would have internalized very early in business school. Anyone who makes it as far as management is going to have that moment where he calls in Daniel Gallant to explain that he's being fired because he forgot to initial at the bottom of page four of Form XXJ-11A one too many times, and the poor dumb sap is going to ask why he's getting run out when Tom Goofus has stuck around for five years despite bungling every assignment he's ever been given. And McArdle just gave you the party line explanation - a track record of success means nothing without proper procedure to prove that it was due to skill and not circumstance. That's going to be about as comforting to Daniel Gallant as the "creative destruction" line is to all those people who just saw their livelihoods wiped out.

(Maybe keep this argument in mind next time you hear corporate bigwigs having seminars on how to increase creativity and innovation among workers. I can think of a way - don't fire them the first time they do something different)

Most of McArdle's readers, being business types, know this already, so I don't know why it's here. But wait, didn't she say something earlier about fail-safes make people complacent? And now she's arguing that we have to follow procedures because otherwise the fail-safes won't work? You can do some mental gymnastics and make those two work together, but that's the point - you, the reader, have to make them line up because McArdle didn't.

And that right there is my overarching criticism of this whole book - it's incoherent. McArdle has a lot of threads - a lot of facts and arguments that vaguely fit the premise - but she never makes any effort to weave them into a greater whole. I can't even say she contradicts herself, because even the individual chapters are such a jumble that it's hard to know what she's saying. Is it good to be bold and take risks, like she seems to suggest in Chapters 1 and 3? Or do we need to minimize risk, like she says in Chapter 4? When something big fails, it's everyone's fault (Chapter 2). It might be someone's fault, but we can't be sure with specificity (Chapter 4). We can't even be sure it's anyone's fault (Chapter 3). We can predict exactly when markets will fail (Chapter 2). We can't predict anything at all (Chapter 3). Failure is a learning experience (Chapter 1). Failure is natural and can't be prevented (Chapter 3). You can, and must, do everything you can to prevent failure (Chapter 4).

The Upside of Down is the illusion of the argument, a fiction created with a storm of not quite on point bits of information. You think you're holding a book, but really it's the hand mirror that McArdle held as she wrote this. It reflects only what you expected to see.


  1. You'd think that a book editor would note the constant contradictions, unlike her blog editor who evidently has been trained to ignore them. Elite failures are systemic; they're signs of risk-taking and knowledge-gathering and lead to success. Lower class failures are due to personal fault, and signs of moral turpitude.

    Elite successes are systemic too:

    "And as development economists have proven over and over and over again, those complex webs of interactions are impossible to tease apart into one or two concrete actions. Things can fail, on the other hand, at a single point. And even when they fail in multiple ways, those ways are usually more obvious than the emergent interactions that produced a success."

    Lower class success, of course, isn't systemic. Like failure, it's based on personal merit, not a system created to help them improve their lives, such as a social safety net.

    I thought McArdle would discuss Medicare when she related the anecdote about her mother. Based on a few things she said, I think her mother was convinced that Medicare provides terrible care and no decent doctors will take Medicare, and therefore put off going to the doctor for too long. Evidently she didn't share McArdle's belief in paying for medical care out of pocket and McArdle didn't volunteer to pay out of pocket for her mother's care.

    I also recollect that McArdle said if her insurance company refuses to pay for her care she yells at them and they change her mind. She has also told us that she's had to have been very sharp with assorted service people who did not serve her well. Why not just yell at the nurses? Or go over the nurses' head? I can't believe that didn't occur to her.

    1. She mentions Medicare briefly, but only to mention that it's hard to find a doctor in D.C. McArdle's way too far into David Brooksian centrism to take a bold stand on anything like that. It's why there's so much innuendo and Broderism in this thing, she has to maintain a veneer of detachment (unless it suits her).