Oct 282013

The press is full of stories about the government shutdown fiasco engineered by  Ted Cruz and those crazy House tea party republicans. But let’s not let this latest clown show obscure our understanding about who’s continuing to drive economic policy in Washington these days. Like they have since the Reagan administration, it’s still the Republicans.

These days, Republicans may be losing politically and resorting to increasingly anti-majoritarian means—gerrymandering, filibuster abuse, voter suppression, activist Supreme Court decisions, legislative terrorism—to nullify election results. But on economic-policy matters they are setting the terms. Senator Ted Cruz can be justly described as a demagogic fool, but lately he’s been on the offensive far more than the White House has. The deficit is in fairly precipitous decline, but job growth is anemic, and millions of Americans remain chronically unemployed. Democrats control the White House and the Senate, and last year they won a larger share of the national vote in the House than Republicans did. And yet the dominant argument in Washington is over spending cuts, not over ways to increase economic growth and address acute problems like inequality, poor schools, and infrastructure decay. “The whole debate over the last couple of weeks is playing against a backdrop of how much to increase austerity, not to invest in the economy,” Neera Tanden, the president of the Center for American Progress, said last week. “We are living in a time of government withering on the vine.”

Need one require supporting evidence for the claim, that’s not hard to find.

It went unnoticed amidst the debt ceiling fight, but last weekend, Democratic and Republican leaders in the House selected the lawmakers that will negotiate with the Senate to hammer out a final version of the farm bill, the massive bill that funds agriculture and nutrition programs. The main stumbling block for months has been how much money the bill should devote to food stamps; the House wants to strip $39 billion from the program, and the Senate wants to cut just $4 billion.

So don’t be distracted by accounts of the Tea Party “defeat.” The most important thing about the increasingly spectacular displays of ridiculousness emanating from the Republican Party is that their circus act is drawing our attention away from an at least equally significant problem — the failure of President Obama and the Democrats to seriously oppose the Republican ideology of domestic austerity.

The domestic economy — all of its major features from high unemployment and job insecurity and the collapse (and bailout) of the banking industry, to the spectacular success of the richest 1% of the population — is a result of forty years of right-wing antipathy to the social safety net and infatuation with unregulated markets. Since the 1970s but mostly since we elected Ronald Reagan, we’ve steadily pursued a consistent policy of deregulation, free trade, and tax cutting, all of which were trumpeted by conservatives as policies which were most likely to unleash economic growth and national prosperity. Despite electing the occasional Democrat as president and despite occasionally handing the reins of power in the House or Senate to the Democrats, these conservative economic policies have continued uninterrupted.  So the world we live in now is the fruit of these conservative economic seeds.

And the conservatives have been correct, in a sense. Certainly, the standard of living of the richest Americans has consistently gotten better since the Reagan administration. There’s been an amazing amount of technological innovation, so if you choose to measure standard-of-living by the ease with which the average citizen can check their email on a smartphone, the economy has been spectacularly dynamic and productive. But of course we also need to acknowledge that for the less-than-rich, this economy has meant flat to declining incomes, increasing unemployment, layoffs, loss of pension benefits, declining public services, and a steady decline in economic security. For the bankers on the level of Robert Rubin, it meant massive government bailouts and the lack of any criminal prosecutions after the subprime loan driven collapse of the banking industry in 2008. For the rest of us, it meant more unemployment and waves of foreclosures. If you don’t particularly like these things; if you believe as I do that the tradeoff of greater wealth and government-backed security for the very rich has not been worth the greater insecurity for the middle class and greater hardship for the poor, then you should be blaming conservative economic policies.

But the blame for these policies is bipartisan. They have been pursued by Democrats as well as by Republicans, and it’s time to start holding the Democrats accountable for their decisions. Don’t let the spectacle of republican wingnuts like Ted Cruz distract you. Clinton and Obama and far too many Congressional Democrats have pushed deregulation and austerity, and they need to be held accountable. Even after the collapse of the banking sector, there’s been hardly a peep from elected Democrats about the need to strengthen the social safety net or break up the too-big-to-fail banking conglomerates. The conversation is still all about how much we need to cut food stamps and social security.

The one exception to this behavior proves the point: Obamacare. This new law designed to increase the availability of health insurance and therefore increase ordinary Americans’ economic security has been compromised, fought, weakened, legally challenged, and filibustered since it first saw the light of day, back when Max Baucus was dragging his feet about every little reform and Barack Obama was preemptively compromising on major issues like single-payer and the public option before he was even pushed. And even now, after the law has been transformed into a mandated subsidy for the private health insurance industry, after several states have refused to participate in setting up state-level insurance exchanges, after the conservatives almost won their constitutional challenge in the Supreme Court, after brilliant neurosurgeon (and political hack) Ben Carson equated the law to slavery, and after Ted Cruz and his wingnut House allies shut down the federal government in opposition, the ACA is still the single example of any initiative by the Democrats to counter the right-wing mantra of cutting government support for this nation’s middle class and poor.

So who’s winning? The Republicans are, but that’s because the Democrats haven’t really cared to fight them. So let’s apportion the blame for the consequences appropriately. Bill Clinton and Barack Obama, this means you.




Aug 192013

strokeassociation FAST

One of the most difficult tasks required routinely of ER doctors is obtaining informed consent for the use of IV tPA in cases of acute ischemic stroke. It is a difficult task because it combines two things that are each — standing alone — among the most difficult things ER doctors are expected to do.

First, we have to decide for ourselves whether or not we want to give tPA. This is an extremely difficult clinical decision. There is a substantial risk of causing catastrophic life-threatening hemorrhage and other serious harm; tPA is not a risk-free treatment. The decision to give tPA must usually be made under conditions of severe time pressure. Studies and guidelines suggesting that tPA benefits victims of ischemic stroke emphasize that it must be given within a very short time period after the onset of symptoms, usually three hours. To complicate matters, the scientific evidence supporting the decision to treat acute ischemic stroke with tPA is not obvious or clear. It is perhaps the most controversial current debate in emergency medicine, with passionate supporters and opponents all wielding literature that is inconclusive and incapable of resolving the debate.

Second, given the risks of tPA, modern medical ethics demands that before we push the drug we explain to the patient or her family members the risks and benefits of treatment to the extent that they are able to give their “informed consent.” In the best of circumstances, obtaining truly informed consent is very challenging. But the circumstances surrounding the tPA decision could not be worse for the patient or family member of the patient — the clock is ticking; they have to make the decision quickly. They are being asked to weigh highly incommensurable outcomes against each other, e.g. death from intracranial hemorrhage, or regaining the ability to speak. In many cases a family member asked to make the decision at one remove — not what I want, but what would my family member want were she able to make the decision for herself. And, of course, the honest physician will inform the patient that the scientific evidence for tPA is not ironclad, and that there is a raging debate among doctors about whether it is beneficial, useless, or harmful.

“So, after all that, what do you want to do, Mrs. Jones? You have, let’s see, about 15 minutes to make your decision.”

My own approach to this difficult task has evolved and will evolve further as I accumulate experience and as more scientific evidence surrounding tPA (and surrounding informed consent) is published. But for now, this is how I approach the problem.

1) It is impossible to familiarize the patient or her family members with the entirety of the tPA evidence in the time they have available for making their decision.

It takes many, many hours for emergency physicians and neurologists to digest the tPA literature; so much so that most busy clinicians rely upon trusted intermediaries to digest the literature for them, pro and con. To then expect that you will be able to fully inform a layperson within the allotted time who is already in great distress from seeing their loved one suddenly immobile on one side of their body and unable to speak is fantasy. So don’t try. It won’t work, and you will be wasting precious time.

2) The goal should be to help the patient or her family member to make a decision that they will be least likely to regret should the outcome turn out to be unfavorable.

Regardless about what the decision about tPA turns out to be, there is a significant chance that the outcome will be far less than perfect. The patient may refuse the tPA and end up paralyzed and fed through a PEG tube for the rest of their lives. Or, the patient may choose the tPA and suffer a fatal intracranial hemorrhage. Post hoc, it will be impossible for anyone to say if the outcome would have been “worse” had the patient made the opposite decision. I don’t think that having a more subtle understanding of the NINDS trial, or being told about the difference between the Cochrane metaanalysis of stroke studies and the ACEP guideline’s review of the tPA literature will do much to alleviate regret if, in this one case, the outcome is bad. What will help is if, in hindsight, the patient’s family can say that the decision was consistent with the patient’s values and overall approach to risk.

3) To maximize the chance that this will be the case, the doctor’s discussion with the patient or the family member should emphasize three informational elements: a) the near clinical equipoise of the published studies b) the choice between potentially reversing the disability caused by the stroke with tPA, and the potential for that drug causing possibly fatal bleeding c) your personal enthusiasm for or against tPA, if the patient asks.

There is rarely enough time for a discussion of much more than these three things, and in the end, these are the three things that matter most for the decision.

4) Remember that the patient or her family member is not being asked to take sides in the controversy over the tPA evidence.

They are being asked to share in the decision making about whether tPA should be given here, now, in this particular case. This is not the same thing as taking sides on the issue of whether routine tPA should be the standard of care across all cases of acute ischemic stroke.

5) Translate the decision into one that the patient is familiar with after a lifetime of making their own high-stakes decisions under uncertainty.

In general, this is the choice between “doing something” to perhaps improve the situation, vs avoiding iatrogenic harm.

Most patients that physicians see tend to fall into one of these two camps. The former will actively take all kinds of medications and seek out all kinds of therapies for even the most subtle of symptoms. The latter will wait until the last possible moment to take that daily aspirin for their heart disease or to see that surgeon for their postprandial right-upper-quadrant pain, in order to avoid iatrogenic stomach ulcers or an inadvertent surgical sponge in the abdomen. If physicians are honest, they will admit that much of their own enthusiasm (or lack thereof) for tPA in stroke is guided by their own tendency to either “do something” or to avoid causing harm.

This choice between action under conditions of uncertainty vs avoidance of action under uncertainty is something that we all, regardless of background or education, understand. It’s a choice that’s fairly thoroughly informed by our general values and approach to living. When faced with the problem of water pollution, for example, some of us dream of huge water processing plants and massive pipelines; others of us dream of discontinuing the production of toxic waste. Faced with the possibility of a stock market crash, some of us short a bunch of stock, others of us put all our money in cash under the bed.

I like to ask my patients “are you a “do-something” kind of person, or are you a “don’t screw things up” kind of person? I tell them frankly that they, or their loved one, is in a very bad position and that the uncertainties are huge. I tell them that the outcome could be tragically bad whether we give or don’t give the tPA. I say that I understand that they are being asked to make a difficult decision in a situation with a high degree of uncertainty and a high likelihood of extremely consequential results, either way. I offer to answer any questions that they have, to the best of my knowledge. I will give them my opinion about tPA: not enough evidence yet to say whether it’s helpful, harmful, or inconsequential — a scientifically unproven therapy that deserves further study.

“So after all that, what do you want us to do, Mrs. Jones?”

Ugh. This is why I’m a fan of doing all we can to prevent ischemic stroke.


Some links I like:

ACEP clinical policy on tPA in stroke [PDF]

David Newman’s SMART EM podcast on tPA evidence

Dr. Newman’s blog post on same topic

Links to Cochrane review of thrombolytics in ischemic stroke

BMJ debate about tPA (and steroid) guidelines and conflicts of interest


Aug 142013

Plunging downhill and nearing the finish of the inaugural Telluride Mountain Run Hill Climb (“Hill Climb”), I had just passed the second-placed female and moved into 5th place overall (fourth male). I was trying my best to run like Ellie Greenwood, who’d flown past me early on the descent and left me wondering a) how that speed could possibly be good for her lower-extremity stress fracture, and b) whether I could ever learn to run downhill that fast. That’s when I started to feel the skin peeling off of both my heels. Uh oh — I was going to be in trouble real soon…

It’s been a few days since the race, and I’m still riding the post-race high. I’m also hobbling around like a duck because of the massive blisters on both of my feet. I don’t know if the blisters will heal in time for the Pikes Peak Marathon this Sunday, but even if they don’t, the Hill Climb will still have been totally worth it.

I’ve been trail running seriously for almost two years*, which at my age (middle) isn’t a hugely long time. Most of that time has been spent watching YouTube videos of famous runners running famous races, people like Kilian Jornet Burgada (whom I named my dog after — it’s a long story), Ellie Greenwood (who was actually on the same course with me at the same time, OMG!) and Dakota Jones (who was one of the race directors of this painful but delightful little race). I have spent a lot of time on trails in the Seattle area and in Colorado, running up and down hills, around trees, through mud, in rain and snow and cold and heat. While I have had fun on every run, I have often wondered whether any of it was making a difference in my ability as a trail runner. Well, I still have little objective evidence of any improvement — I don’t faithfully time myself on the same routes or repetitively try to beat my PBs on a given trail (hey, I’m not Anton Krupicka). But my subjective experience at the Hill Climb is that yes, I’m getting better. That is hugely motivating.

On to the blow-by-blow, which in an eight mile race isn’t going to be a long drawn out kind of thing. I could paraphrase Dakota after his 2012 Lake Sonoma 50 victory: “I ran alot, and then I finished sixth.” But I know you want to know what it was like, so I’ll elaborate.

1) Cameron Clayton disappears: It was fun to start the race in the same small field as elite runner Cameron Clayton, who had just come off an uncharacteristically low (for him) 14th place at Speedgoat against a world-class field. As we started to climb, he moved out ahead of the pack by about ten feet, turned back and said something like “anyone coming with me?” and then took off up the hill and disappeared into the distance without anyone going with him. I can’t be sure that’s what he said — I was surrounded by the sound of huffy breathing and stomping feet, so I might have heard wrong. Anyway, it was exciting to run alongside him for about fifty yards or so. This is why trail racing is so fun!

2) Mucus Monster. I caught a cold a few days before the run, and this resulted in massive quantities of mucus in my upper respiratory tract, which extruded itself during the race on account of all the heavy respirations I was doing. This didn’t seem to slow me down during the race, but it was annoying and probably very unsightly. Good thing I’m not a sponsored runner who has to look good for the photographers!

3) Steep as Sh#t: This course was steep. Which meant that most of my climbing was done in power-hiking mode. It was amazing to watch Cameron Clayton and Marco Zuniga actually run that grade, and even more amazing to watch Simon Kearns (age 13) do the same. Both of them took off right from the start and I was sure I’d never see them again on the uphill.** I climbed more-or-less (OK, slightly less overall) at the same rate as former Imogene Pass Run winner Kari Distefano, me passing her, then her passing me. Her style was to run the whole thing — I guess it’s just a matter of what gait is most efficient for you.

3) “Beating” Ellie Greenwood: I reached the turnaround point at the top of Gold Hill ahead of Ellie Greenwood. That is amazing. Yes, I know that she does not consider climbing hills to be her strength. I know that she had just arrived in Telluride from sea level. I know that she had not raced for months because of a stress fracture. I know all of those things, but still — Ellie Greenwood! For the non-cognoscenti, I mention that she was the one who finally broke Ann Trason’s record at Western States. Then there is Comrades, and the long ultrasignup.com list of almost unbroken victories — read all about her as much as you want, and then you will understand that it was exciting to get to the top of the hill ahead of Ellie Greenwood. Even though she was far from full strength. It was cool!

4) Being blown away by Ellie Greenwood on the descent: Soon after the turnaround at the top, Ellie Greenwood blasted past me on the descent. Which reassured me that I was not running in some alternate-reality universe. Before she disappeared down the hill, I paid close attention to how she was running the downhill, and while I can’t claim to have learned any super-secrets, I will say that I saw her running very fast. I will try to put this lesson into practice in future races.

5) Battling Kari Distefano: She and I had traded places a few times on the ascent until she pulled away slightly just before the top. But on the descent I found that I was gaining, and that was exciting! I knew that if I pushed just a little bit harder that I would beat her to the finish. So I pushed. And I passed her!  And then the skin peeled off my heels, and I was running on my toes to avoid the pain of the heel blisters, and my calves started cramping because I was running on my toes, and she passed me, and I finished sixth overall instead of fifth. Drat. It was also disappointing to have to hobble past Ian Sharman who was taking pictures near the finish, but hey, I will survive.

To sum up, the Hill Climb was a great experience. Dakota and Reese were right on two counts: there were mimosas at the aid station, and I did finish in the pain cave. It may or may not have been a sign from God that yes, all my trail running has made me a better trail runner (I’m militantly agnostic about the existence of God, you see), but it has motivated me to keep trying to get better, and to keep racing. I thank everyone who ran faster than I did: Cam Clayton, Marco Zuniga, Patrick Hummel, Ellie Greenwood, and Kari Distefano — you all inspire me to get faster.

I thank the RDs for all their hard work. As a runner, I look at the race directors the same way I look at the hosts when I go to a party: I’m glad you do it, because I would never want to do it! All the planning, all the preparation, all the clean up… whew! Thanks for the pint glass. I needed another one of those. Thanks for the T-shirt; it’s one of the best-looking ones I own. I hope this race happens again next year. Ideally, I’d like to see the hill climb done a day before the long run, so the hill-climbers could volunteer at the mountain run (or do them both). In a perfect world, I’d like to be able to do this race with my dog, because running with my dog is always better than running without my dog. But I realize that yes, the permits are tough enough to get without allowing dogs, and probably impossible with allowing dogs. But I can dream… dogs!

* I have done the Pikes Peak Marathon three times, and the Pikes Peak Ascent once, back when I was in medical school, but I didn’t really train for those races and wasn’t training for anything else, either.

** I did manage to pass Simon right near the top of the hill. Cameron, well… I saw him on his way back down. Briefly.



Jan 082013

Andrew Sullivan is taking a chance that his readers are willing to pay for subscriptions to his blog.  Good for him!

(Here’s Andrew Sullivan on his new model with links to some commentary.)

(Here’s Peter Osnos on what this means for publishing.)

It’ll be fun to see whether his business model pans out.  Especially because it’s been obvious for a while that the old big-media business models are living on borrowed time.  Traditional newspapers aren’t making money; print book publishers can’t sell as many copies now that we all have Kindles, and blogs…  I wasn’t aware that internet blogs were suffering, but I’m not an expert on these things.

The question I have as a reader is, should I pay money for access to Andrew Sullivan’s blog?

Let’s assume for the moment that I’m a faithful reader of Andrew Sullivan.  (I’m not, but I am an occasional reader of many blogs very similar to his, and like anyone else who spends any time online, I occasionally stumble onto his site and read for a bit.)  So up until now I’ve been able to read his blog for free.  As it stands now, I wouldn’t pay for a subscription, because…. his content is cheap and ubiquitous.  This isn’t meant in any pejorative sense.

If Sullivan’s blog is no longer available to me, I know of a thousand other blogs, twitter feeds, online discussion forums, etc., where I can get opinions about current events, held by other people, for free.  About the only thing special about Sullivan’s blog, is that it lets me read about what Andrew Sullivan thinks.  No disrespect is intended towards Andrew Sullivan, but he’s not particularly special in that regard.  (His award section is pretty good, though.)  He doesn’t have any special expertise; his opinions aren’t generally too provocative or too far out of the mainstream, his topics of discussion are pretty generic and easily found on hundreds of other sites.

Again, Sullivan’s content, as it stands now, is cheap (because it’s almost indistinguishable from enormous heaps of other internet content about the same subjects) and ubiquitous (because Sullivan is just a blogger — no disrespect intended — and not a subject-area expert or journalist or office-holder).

The special things about Sullivan’s blog, for me, are that he posts frequently and there’s always new content.  He posts lots of links.  His site is a good place to spend time on the internet because these two things.  But if I really need more links to Matt Yglesias (I don’t), I can easily find them elsewhere on the internet for free.

None of this is intended as a criticism of Andrew Sullivan.  It’s more a judgment about the value of bloggers generally.  Right now, the market is saturated with competent and diligent bloggers that I can read for free.  There’s just no need to spend money on Andrew Sullivan.

Here’s some of the things I would be willing to spend money for:

a) subject-matter expertise.  For example, I already spend money for Mel Herbert’s online offerings, because of the special emergency medicine subject-matter expertise his sites offer.  If sites like Corey Robin (political philosophy) or iRunFar (ultra-distance running) went behind a paywall, I would seriously consider subscribing to those sites because I can’t easily find substitutes for free, like I can with Andrew Sullivan’s opinions.

b) new information, i.e. journalism.  Reporting is still different from blogging, in that it uncovers new information that isn’t already on the internet already.  Reporting injects new facts into the public awareness, whereas blogging at its best injects new interpretations, analyses, and opinions about those facts.  Reporting is much less ubiquitous than blogging.  As soon as the Washington Post goes behind a paywall, I plan to start paying to read it, the NYT, the WSJ, etc., because I can’t find good reporting online as easily as I can good blogging.

Andrew Sullivan has said that he’s contemplating whether or not to commission some long-form journalism, and if he does that, I’m much more likely to subscribe.  I’ll spend money for opinions, but usually only if they’re really deep dives into a topic or if they’re buttressed by extensive research (these are usually published as books; a great example is Chris Hayes’ Twilight of the Elites.  I wouldn’t pay money to access a Chris Hayes blog for the same reason I’m not paying for Andrew Sullivan’s blog.

Jan 072013

UCI president Pat McQuaid’s behavior since the fall of Lance Armstrong clearly illustrates a certain kind of leadership style.  Call it the “screw you”  or autocratic style, most familiar to Americans in the leadership style of George W. Bush.

The chief assumption of this style of leadership is autocracy — the expectation that followers or underlings are not entitled to question the leader’s decisions.  This autocracy can be term-limited, and the leader’s underlings might be entitled to change their leader every so often in very prescribed ways (usually through periodic elections), but apart from that, the autocratic leader is entitled to unquestioned deference during their term as leader.  The pithiest description of this style was given by George W. Bush after the 2004 election, when questioned about his Iraq policy:  “Well, we had an accountability moment, and that’s called the 2004 election. And the American people listened to different assessments made about what was taking place in Iraq, and they looked at the two candidates, and chose me, for which I’m grateful.”  Accountability is something that the autocratic leader is subjected to in brief moments; outside of those, he need not give an account of himself to anyone.

The autocratic style is very useful in some circumstances.  Under severe time pressure when high-stakes decisions need to be made quickly, you want an autocrat and not a consensus-builder.  When the time for debate is short, and the need for rapid execution of a plan is high, you don’t want a lot of questioning of the leader’s decision.

But is that what the UCI needs right now?

It’s certainly what the UCI has.

Ever since Lance Armstrong fell off his pedestal after the USADA convincingly demonstrated that he’d been a hard-core doper and liar for virtually his entire cycling career, Pat McQuaid has acted as if it’s outrageous for anyone to suggest that he resign.  Greg LeMond, who has called for McQuaid’s resignation, is “arrogant.”  The media is “mischievous.”  Jamie Fuller’s funding of Change Cycling Now is a “stunt.”  Even as he acknowledged that the USADA report was damning enough to strip Lance Armstrong of his seven Tour de France wins, McQuaid was criticizing USADA for having a conflict of interest and including “incorrect and incomplete” statements.

McQuaid has other options than to respond this way.  McQuaid could, very reasonably, say something like this: “I understand that fans of cycling, and riders themselves, have plenty of reason to question whether or not the UCI’s leadership has failed in its very important role of ensuring that professional cycling competitions are fair.  That riders talented enough to compete at the top level of the sport are also free of undue pressure to take performance-enhancing drugs.  I have been in this sport for a long time, and I believe that the UCI under my leadership has done its utmost to ensure fair competition.  I do not believe that anyone else could have done more.  But nevertheless, the perception of an omertà in the peloton is not insignificant or trivial.  The doubts of the fans are not inconsequential.  I love this sport.  I place it first in everything I do.  Therefore, as a way of combating the reasonable perceptions that the Lance Armstrong affair has generated for many, I think the sport would be best served by a leadership change at the UCI.  I resign because it’s the best thing for the sport.”

This would be something that many leaders might reasonably do.  But to take this step, you’d have to believe, as Pat McQuaid does not, that criticism of his leadership might be motivated by a genuine concern for the health of the sport, and that not all critics of his leadership are “scumbags.”  He’d have to believe that there are reasons to resign other than dereliction of duty, or incompetence — that sometimes even an inaccurate perception that a leader is corrupt is best refuted by a voluntary relinquishment of that leadership.

The telling evidence that Pat McQuaid is incapable of varying from his autocratic style is that he’s failed to acknowledge any of the criticisms he’s received as even remotely valid.  Every critic, according to McQuaid, is a scumbag performing some stunt or another.  Never mind that the Armstrong affair is the biggest scandal to hit cycling in our lifetimes, and that it was dragged into the light with the UCI kicking and screaming the whole way.

Is that the kind of leadership the UCI needs?  I think not.  The problem with the Armstrong affair is that it demonstrates that the UCI failed (for whatever reason) to uncover the “most sophisticated, professionalized and successful doping program that sport has ever seen.”  The UCI must acknowledge its responsibility for that failure.  Because Pat McQuaid will not acknowledge its responsibility, Pat McQuaid should resign.