Privately held Wegmans—which had 2004 sales of $3.4 billion from 67 stores in New York, Pennsylvania, New Jersey, and Virginia—has long been a step ahead. Its former flagship store in Rochester, opened in 1930 by brothers John and Walter Wegman, featured cafe-style seating for 300. Walter's brilliant and pugnacious son Robert, who became president in 1950, added a slew of employee-friendly benefits such as profit-sharing and fully funded medical coverage. When asked recently why he did this, 86-year-old Robert leans forward and replies bluntly, "I was no different from them."

Robert is chairman now; his son Danny, a sartorially challenged Harvard grad who came back to Rochester to cut meat for Wegmans, took the reins in 1976. Early on, Danny was keenly aware of the threat posed by nontraditional grocery outlets like club stores and discounters. (His 1969 senior thesis ended with these prophetic words: "The mass merchandiser is the most serious outside competitor to ever face the food industry.")

In 2003 those nontraditional grocers had 31.3% of the grocery market, and industry guru Bill Bishop projects that number will grow to 39.7% by 2008. That's because consumers think traditional grocers don't offer anything special; 84% believe all of them are alike, one survey has found. Most grocers responded to the competition by slashing prices, wreaking havoc on already razor-thin margins. From February 1999 through November 2004, the four largest U.S. grocery chains (Albertson's, Kroger, Safeway, and Ahold USA) posted shareholder returns ranging from -49% to -78%. Winn-Dixie Stores was booted out of the S&P 500 in December for its horrendous performance.

You don't see such problems at Wegmans. While it has no publicly traded stock, its operating margins are about 7.5% (the company will not disclose net margins), double what the big four grocers earn and higher even than hot natural-foods purveyor Whole Foods. Its sales per square foot are 50% higher than the $9.29 industry average, FORTUNE estimates, thanks to a massive prepared-foods department featuring dishes that rival those of any top restaurant. (Wegmans asked famed Manhattan chef David Bouley for input.)

Each of the newer Wegmans stores is 130,000 square feet—three times the size of a typical supermarket. That means it can offer true one-stop-shopping for every taste. And unlike Whole Foods, which disdains products containing pesticides, preservatives, and other unhealthy stuff, Wegmans stocks both organic gourmet fare and Cocoa Puffs, at competitive prices. That vast selection helps explain why in places like Rochester, Syracuse, and Buffalo, the zeal for Wegmans often borders on kooky obsession. In 2004 the company received nearly 7,000 letters from around the country, about half of them from people pleading with Wegmans to come to their town. Ann Unruh, 52, an insurance manager in Sparks, Md., who has never set foot in a Wegmans, is so excited about a store opening in her area later this year that she plans to take the day off work to be there. She says there will be no need to visit Whole Foods anymore: "I will just shop at Wegmans."

Each Wegmans store boasts a prodigious, pulchritudinous produce section, bountiful baked goods fresh from the oven, and a deftly displayed collection of some 500 cheeses. You'll also find a bookstore, child play centers, a dry cleaner, video rentals, a photo lab, international newspapers, a florist, a wine shop, a pharmacy, even an $850 espresso maker. "Going there is not just shopping, it's an event," says consultant Christopher Hoyt. In an annual survey of manufacturers conducted by consultancy Cannondale Associates, Wegmans bests all other retailers—even Wal-Mart and Target—in merchandising savvy. "Nobody does a better job," says Jeff Metzger, publisher of Food Trade News.

Here at home, 2004 brought us politicians shamelessly plucking the broken heartstrings of unemployed textile workers. It would have made sense for politicians to help the industry get ready for this day – it was 10 years coming, after all – but the horse was out the barn before the election year began. If they could feel shame, they’d be feeling it now.

There are still issues with China, certainly, and no one can blame the domestic textile industry for trying to get some relief from the government. But we certainly cannot blame China for a directive issued Dec. 13 from the Committee for the Implementation of Textile Agreements calling for U.S. Customs to hold fabrics that entered U.S. ports near the end of the year in excess of quotas.

In years past, fabric that was over quota near the end of a year was counted against the next year’s quota. But since the quota is now gone, the committee felt that some importers might deliberately ship goods in excess of quotas limits, expecting that the goods would be released on Jan. 1.

This decision has created trouble and expense for some upholstery fabric importers. Their goods, ordered in good faith in October from mills that held valid quotas, were declared to exceed quota limits when they arrived in December. Obeying the directive from CITA, Customs put the goods into bonded warehouses where they will stay until Feb. 1. At that time, they will be released in 5% per month increments of the amount over the base quota.

Textile lobby groups such as the American Manufacturing Trade Action Council applauded the decision. “It was the very least the government could do,” said a spokesman, adding that that the embargo “should be a lesson to people about the risks of doing business with overseas companies.”

A spokesperson at the United States Assn. of Importers of Textiles and Apparel countered that the action was  action “pointless, without merit and just plain mean.”

Since most imported textiles are apparel, a lot of upholstery fabric suppliers felt confident in late December that the embargo would not impact their business, stating that they typically have some goods held at the end of the year, which then are released on Jan. 1. Some of these companies were surprised to learn when they arrived back at work after the holiday last week that the goods had not been released on Jan. 1 but will be held till Feb. 1 and then trickled out incrementally over a period of months.

Here's a Reuters background article on the end of textile quotas are here. The NYT and WSJ have covered the story repeatedly, but they're hard to link to. One of the points made by Bill Lewis in The Power of Productivity, which I wrote about here, is that India's restrictions on the size of apparel factories has made the industry much less efficient than China's.

For the next year, McClintock watched from the Senate as Schwarzenegger learned the ropes in the Capitol, compromised with Democrats, avoided confrontation and, in the end, made little progress on the fundamental problems that bedeviled the state. The senator offered muted criticism when appropriate, support where he could.

Then, Wednesday night, suddenly everything changed. It was if the flashy governor were channeling his straight-laced colleague. Schwarzenegger's speech sounded almost as if McClintock had written it.

"Maybe I should have copyrighted some of my ideas," McClintock said with a laugh when I asked him later about the resemblance.

McClintock, some might remember, was one of only a handful of lawmakers to vote against a pension bill in 1999 that boosted state retirement benefits and paved the way for a wave of local pension increases that have threatened the financial solvency of some cities and counties. Three years later, McClintock was the only legislator to vote against a lavish new contract for the state's correctional officers, or prison guards. And all along he warned that the state's spending growth could not be sustained.

Now Schwarzenegger was saying that pension bloat, the guards union and other ills McClintock has spotlighted over the years were the heart of the state's problems. And with no apparent bitterness, McClintock endorsed the Schwarzenegger agenda.

Read the whole column here. The Weintraub column archive is here.

The article isn't about waitress moms, of course. It focuses on what we used to call yuppies, before they moved to the suburbs. Among the professionals profiled, I suspect that economics, not some sort of moral conversion, explains most of the trend. If you're a highly skilled, highly educated professional, you can make quite a good living these days without working terribly long hours or putting your work first. (You can, of course, make more if you work obsessively. But even the most rationalistic economist believes people maximize utility, not income.) And, contrary to widespread belief in places like LA, Washington, and New York, in most of the United States, a family can live a comfortable middle-class life on middle-class pay, in many cases on a single salary. You won't have every luxury, but you'll have more than your parents.

Back in the pre-Slate days, Mickey Kaus took another angle on the same general trend--baby boomers who don't really have to work that hard to live.

Remember, torture (notably but not exclusively rape) goes on every day in our domestic civilian prisons, with far less justification than interrogation, and we make jokes about it on TV shows. That most of this abuse is by prisoners of prisoners doesn't excuse the justice system, which is not merely indifferent but complicit, using the threat of prison abuse to coerce pleas.

Thanks for posting the link to Atul Gawande's interesting article in the New Yorker.  I do think Gawande, who in general is quite good at writing about medical topics for general audiences, went astray this time in hanging the article on the implications of the bell curve.

Another way of looking at the objective of Berwick and his followers is to think of it as pushing the entire performance curve up and reducing its spread so that even performers who are, in a mathematical sense, below average nonetheless deliver a level of quality that is entirely satisfactory in a substantive sense.  If they succeed, then why should anybody care who is below average?

Of course, there will be some lumps and bumps along the way from here to there, as low performers have their consciousness raised by being publicly "named and shamed".  But the response Gawande describes in Cincinnati is consistent with much else in the literature in supporting an optimistic view of the impact on patients' attitides of the candor and good faith effort that Berwick preaches.

There may be a very few domains of medical practice, perhaps especially in certain areas of high-risk surgery that require truly virtuosic manual dexterity, where there just can't be enough high-quality practice to go around.  But it's not obvious that this is true, or if it is that it can't be solved in time with computer-guided mechanical assistance - and it's anyway doubtful that this is the rule more broadly. In the meantime, there's so much low-hanging fruit still to be picked in health care quality improvement that it doesn't make sense to waste too much of one's energy worrying about theoretical extreme cases.

The really hard, really interesting issues, and many, many fascinating stories, lie elsewhere.  How do we know what constitutes best practice, anyway?  Berwick drew his own inspiration from the pioneering quality improvement work of Deming and his colleagues.  But the application of these methods to health care is not without controversy.  There's a very nice point-counterpoint on this in JAMA in 2002 (full references below, in case you're interested).  The competing position in the JAMA debate, the reigning dogma that true knowledge is derived from controlled clinical studies, also has its problems when you dig deeply enough into its conceptual foundations.

Despite the vogue for "report cards" and the genuine benefits that can be achieved through their careful use, assessment of health care outcomes, or more particularly reliable attribution of cause and effect, remains a huge problem.  Our ability to adjust outcome measures for pre-existing risk, and thus draw attributions from purely observational data, is still fairly primitive on the whole.  This is something that Gawande does acknowledge in a nice passage, but dismisses a little too easily in his rush to lay on the psychological dilemmas of being graded on a curve.

How physicians manage to grope their way forward through this epistemological fog and make real, tangible improvements in health outcomes, and how to arrange things so that they can see more clearly and make more rapid progress against the inertia of existing institutions and practices and vested interests, is one of the great, ongoing stories of our time, for much more interesting reasons than this article allows.

We can certainly use more writers who can figure out how to explain this stuff with sufficient clarity to the general public so that they understand what the issues really are, and how to demand better in an intelligent way.  In fairness, Gawande's writings as a whole are a valuable contribution to public understanding - it's just a pity he stumbled a bit this time.

Sources:
"What Practices Will Most Improve Safety? Evidence-Based Medicine Meets Patient Safety, Leape LL, Berwick DM, Bates DW, JAMA 2002 July 24;288:501-7
"Safe But Sound: Patient Safety Meets Evidence-Based Medicine," Shojania KG, Duncan BW, McDonald KM, Wachter RM, JAMA 2002 July 24;288:508-13

And for crosscultural fun, check out his Museum of Foreign Groceries.

One hopeful sign: This column by the WaPost's Anne Applebaum, who's the furthest thing from a partisan hack--an intellectual with real ethos on human rights. Maybe, just maybe, we'll get a serious discussion, at least outside the halls of Congress.

Thank you for a thoughtful post and letter. Obviously I disagree with some of your sentiments, but I appreciate the cordial tone of the conversation. As you know, we bloggers receive worse at times.

By way of response, I have several points:

1) As I mentioned in one of my final posts on the subject, I regret even addressing Dr. Gawande's theory about physicians being distributed on a bell curve. While I disagree with the theory, I do find it provocative and indeed obvious that there is a bunch of below average physicians out there (roughly 50% by my math). But my sole beef (and the cause of my vehemence) was with Dr. Gawande's methodology concerning the CF community.

As Steven's letter acknowledges, Dr. Gawande reaches some dramatic conclusions based on a crude univariate study. Looking at two different CF treatment centers, Dr. Gawande found the patients' life expectancy at one to be 50% higher than at the other. He attributed this disparity completely and entirely to the differing skills of the physicians at the centers, but never addressed or considered other possible contributors to this outcome. Is it too much to ask that such a study be a careful multi-variate study?

I will, however, acknowledge that there is nothing in the doctor's article that disproves his thesis. Once again, my approach was flawed in so much as I addressed his theory where I should have limited my critiques to his sloppy analysis of the CF centers' data. My sole interest here was to reassure members of the CF community that Dr. Gawande's conclusions regarding the Cincinnati doctors and the implications those conclusions might have for other physicians were not necessarily justified and would most certainly not be justified by a simple glance at a CF center's mortality rates and its patients' lung functions.

My misguided tack in regards to not limiting myself to the doctor's CF center analysis has caused several observers to overlook my principle complaint and focus on defending the Doctor's theory. Moreover, I would agree that discarding the doctor's theory because of his suspect CF center analysis would indeed be throwing the baby away with the bath water. His thesis most certainly merits further study.

2) All of the numbers I cite are easily available at CFF.org except for the average number of patients per accredited CFF center and that was based on a simple calculation (going off the top of my head, there are roughly 115 centers and roughly 23,000 patients at those centers - that's where the number of 200 per center came up). If you truly doubt my contention that a CF patient's genetic variant is by far the largest determinant of his fate, ten minutes of research will dispel the doubt. There is nothing in any of my pieces that is not completely accepted by the entire CF medical community and the medical community at large.

3) The Minneapolis center is a great center, but it does nothing differently from the other 115 centers in terms of wildly different treatments or anything else that could be labeled innovative. The doctors at Minneapolis would tell you as much. Ironically given the terrain of this conversation, the greatest benefit of the CFF's Quality Improvement Initiative has been the rapid diffusion of information across the network. Any successful innovation at a CF center literally anywhere in the country becomes common practice almost overnight.

What the Minneapolis center might well do is get its patients to comply with a grueling CF treatment regimen marginally better than the physicians at other programs. That is a factor that I addressed in one of my posts. I believe The Foundation has done studies on the difference made by patient compliance. Sadly, this is another area of inquiry that Dr. Gawande completely ignores.

4) To address a few specific points from your letter (I offer your quotes first and then my response in italics):

"Unless patient turnover is negligible, that militates strongly against the suggestion that it is all the luck of the genetic draw."

To the best of my knowledge, patient turnover is indeed negligible. Again, this is the kind of thing Dr. Gawande clearly should have considered and quantified before reaching his conclusions. I'd be quite surprised if there isn't solid data available on this issue.

"If patient turnover is negligible, then at best one could argue that there are genetic types that are not only easier to treat but that have initially hidden pathways to improvement not present in other types."

Before addressing that point, I should mention my credentials. I'm 37 years old and have CF. I'm also a Harvard grad and a lawyer. Mastering the body of knowledge that exists regarding CF is an achievable task for any well motivated and reasonably intelligent person. It is the good side of the sad fact that the body of knowledge regarding CF is so slim.

So, respectfully, your last quote indicates a lack of awareness regarding CF. As a rule, CF patients don't improve, they only get worse. CF has no cure and more relevantly, no control either. Those with the milder genetic defects decline at a slower rate. Their superior fate comes about because of this factor, not because they "get better." Sadly, we seldom get better. Arresting the disease's progress and on occasion regaining some incremental lost ground is the best we can hope.

I would also guess that it is not the "bad" cases that skew a center's numbers, but the "good" cases. A cluster of mild cases in Minneapolis several decades ago would have skewed their numbers from literally the 1950's into the present day. Again, a more thorough analysis than Dr. Gawande's would be instructive in this regard. Which brings me back to my original beef - Dr. Gawande made dramatic conclusions without performing the necessary research.

5) Finally, regarding the CF Foundation's lauding of the New Yorker article, the Foundation's statement in fact lauds itself, not the New Yorker article. The Foundation has most certainly not issued a statement that even in the slightest way praises the article's methodology, although the Foundation does appear to be quite satisfied that Dr. Gawande compliments their QII. The QII is indeed a visionary initiative, which makes it all the sadder that it has become imperiled by Dr. Gawande's article. Although I don't have any inside information regarding the Foundation's thinking regarding this piece, I'm quite confident they earnestly hope that this article disappears before at least 50% of the CF community begins screaming holy murder regarding their sub-par or mediocre physicians based on the flimsiest of data.

In conclusion, Dr. Gawande's analysis regarding the CF centers was gravely flawed and remarkably irresponsible. As a physician and a man of science, he should have known better.

I appreciate the opportunity you've given me to forward this conversation. Best wishes to both of you for a happy and healthy New Year,

James Dwight

Here's Steve's reply:

Thank you for your gracious response to my email. I understand why you believe it so important to avoid spreading erroneous information about CF treatment. I share your concern. What I do not share is your conviction that inter-clinic differences in treatment are likely to be unimportant factors in explaining differences in patient outcomes. Such a conviction contradicts the evidence in many other fields, from software to manufacturing, where large performance differences across superficially similar units are pervasive. The sources of these differences and the factors explaining their persistence are an important topic in modern business strategy research.

It is also clear that we agree on the need for serious econometric analysis of the CF QII data. There are plenty of experts in economics or health policy qualified to perform such work--I wonder if or when they will have an opportunity to do it. In Bayesian terms, our priors about the results of such analyses differ; you expect that most inter-clinic variations in lung function are due to the luck of the draw, while I suspect that systematic organizational factors are at work. But I am glad that you are not ready to dismiss the thesis of inter-clinic performance differences ('the baby" in your terms) simply because of a lack of rigor in Gawande's discussion ("the bath water").

We also disagree about the merits of Gawande's article. You point out that he should have mentioned the influence of genetic factors, and I can hardly disagree, but without quantitative evidence I am not prepared to say that these differences play any significant role in explaining the differences across clinics. Unless you believe Gawande deliberately suppressed information about genetics, I find it hard to believe that either the doctors in Cinncinati or those in Minneapolis would have failed to mention this if it were an important factor in their success rates. Especially in Cinncinati, where they were trying very hard to improve and wracking their brains to close the gap, it would surprise me greatly if no one said "Hey, maybe we're doing everything right but just got stuck with tougher patients." In my experience, that type of self-justification tends to appear quite frequently even when there is no evidence to support it; if your theory of random differences were the accepted explanation, the Cinncinati staff surely would have mentioned it to Gawande.

Furthermore, you write as if Gawande gave short shrift to the influence of patient compliance. To the contrary. His long illustrative anecdote about why Minneapolis is different and better highlighted the unusual and determined effort the lead physician made to ferret out hidden acts (and causes) of noncompliance. The anecdote also showed how cabining off the effects into "patient compliance" is misleading, because the way in which non-compliance was detected was through a much more meticulous tracking and accounting for small changes in lung function and weight. It is highly reminiscent of the quality revolution in manufacturing, where statistical analysis tells you when your process is drifting and you then deploy an exhaustive diagnostic process (fishbone charts, "ask why five times,", etc.) to hunt down and eradicate the source of the problem. Minneapolis was doing this and Cinncinati was not, at least in Gawande's account.

At the risk of taxing your patience, I'll briefly comment on your responses to my seven points:

1) On the truncation of genetic variation in the snapshot clinic population due to rapid attrition of the hard cases, we appear to agree. You argue that the real issue is a long tail of mild cases. I would like to see some data on the true variation in means across genetic types with and without the truncation effect. I suspect that the actual range of severity found with truncation is quite a bit smaller than the theoretical range possible.

2) From your response, it appears you do not disagree that the number of genetic variants is not particularly crucial; what matters is the range of severity among those variants. We do not know those numbers. You say that "a CF patient's genetic variant is by far the largest determinant of his fate," but the precise empirical question brought up by the QII data is how much "by far" really means in quantitative terms compared to clinic performance. And of course, even if genetic variant explains most of the variance across the entire population, there could still be huge differences in clinic performance conditional on a specific genetic variant.

3) It seems we now agree that it is possible for physicians (or clinics) to follow a bell curve in effectiveness even if they come from a rigorously selected population. A possibly picayune point here is that the fraction of physicians falling below the mean could be much greater or less than 50% if the distribution were NOT symmetrical like a bell curve. In a world with a few superstars and the rest clumped fairly closely together, well over half would be below average, while in a world with a few superduds and the rest clumped together well over half would be above average.

4) You assert that the Minneapolis clinic "does nothing differently from the other 115 centers in terms of wildly different treatments or anything else that could be labeled innovative." This claim captures, in a nutshell, why total quality programs are so hard to implement. People simply have trouble accepting that many small, subtle differences in approach can cumulatively yield drastically different performance levels. The patient compliance methods used at Minneapolis are, you concede, different and possibly superior, as Gawande reports in detail (not "completely ignores," as you state in your response). As I mentioned above, these techniques appear to be part and parcel of a different approach to monitoring and intervention. And I continue to find it unlikely that the clinic that pushes these techniques with such unusual vigor would also just happen to get the best genetic draw from its patient pool.

5) You present an intersting theory that the persistent and IMPROVING performance gap between the "best" clinics and the others is due to fluke clusters of mild cases taken in forty years ago. Because these mild cases deteriorate more slowly than the others, the clinics that have them will show relative improvements over time; and since these mild cases live longer, they will keep skewing the statistics over a longer period of time. This is a theory could be tested if the genetic data are broken out in the QII program. Note that your theory is just about the only way to rationalize the long-term and increasing superior performance of the leading clinics.

I am skeptical of this explanation for a few reasons. First, there has to be plenty of patient turnover, simply due to deaths, relocations, new cases, etc. This would tend to wash out lucky genetic draws unless certain geographical areas have distinct genetic profiles (not out of the question, I suppose--lots of Scandanavians in Minnesota, lots of Germans in Cinncinati, etc.--but I'd really need strong evidence to buy into that). Second, Gawande reports that some CF patients do improve when their treatment regime changes--the Minnesota clinic, for example, believes that it can get lung function to go up from 90% to 100% or better by improving patient compliance.

6) I still think it is relevant that huge performance differences across hospitals have been found on items as simple as giving pneumonia vaccines to elderly patients as indicated by best-practice guidelines. This suggests that it is not far-fetched that CF clinics would also show significant performance differences.

7) We will have to agree to disagree about the CF Foundation's website press release on the Gawande article. You are correct that they are not "laudatory" to the article itself, as I initially wrote, but they seem very happy about it and express no qualms of any kind about how it is interpreted or whether it will scare off clinics from participating. If they had such concerns, I can't imagine them not putting up some kind of caveat. If they "earnestly hope that this article disappears" then putting out a positive press release seems quixotic.

My conclusion is that Gawande's article, while falling short of the standards of social science, provides a useful journalistic window on the issue of performance differences among medical practiitoners. If it turns out that this story is indeed a statistical chimera produced entirely by natural variations (like the many bogus "cancer cluster" scares), then either Gawande's sources were unaware of it or Gawande is grossly dishonest or incompetent. But if, as is more likely, these performance differences are real and not artifacts, then Gawande has performed a service to the public understanding.

I am going to cc this missive to Virginia--I don't know what she'll do with it. I understand if you are tired of this subject. I do not intend to continue this colloquy any further, so you may have the last word or ignore it as you choose.

Best of wishes for the New Year.

--Steven Postrel

By mutual agreement, that ends their public discussion.

Andrew has a point about what the "inning of Susan Sontag" says about the media's continuing assumption that homosexuality is shameful. Of course, the obit writers might argue, it's not like she was married to Annie Leibovitz. From what Andrew says, it sounds like an on-again/off-again relationship of the sort that wouldn't merit mention in an obit if Leibovitz were a man--unless, of course, that man was a world-famous photographer whose work, and conversation about that work, surely influenced Sontag's thinking on the subject.

And while we're on the subject of the late Ms. Sontag, what definition of intellectual makes this sentence from Charles McGrath's Week in Review item true? "Susan Sontag, who died last week at the age of 71, was the pre-eminent intellectual of our time--visible, outspoken, engaged." Surely we can do better.

As reports of the tsunami death toll seem to double daily - the latest count exceeded 120,000 - the demand for communications rises almost as fast as the need for food and water. But where wires have washed away, wireless broadband can bring crucial communications for disaster relief, and a variety of companies are gearing up to offer wireless aid.

This week Cisco Systems announced just such an effort. Working with the NetHope consortium, an alliance of companies and relief organizations, Cisco plans to make NetRelief Kits for the devastated South Asian regions. The kits create an easy-to-use wireless connection with core access coming from satellite company Inmarsat. The kits were created specifically for real-time disaster management and NetHope is currently trying to determine the best locations for deployment.

"A satellite signal is particularly useful in a desperate situation," says Julie Ask, a senior analyst with Jupiter Research. Ms. Ask says that using a satellite signal to create a core to a wireless network, and then deploying wi-fi access or extending the range through a mesh network, would be an ideal way to get information infrastructure to residents and first responders. Users could access the wi-fi connection for VoIP or data services, and because of the high bandwidth, the network could move data-rich content like maps of the terrain, schematics of buildings, or satellite photos of the landscape.  

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