A Time To NOT Volunteer

If you know me or you’ve come by this blog a few times, you know I’m very passionate about the role of volunteers in the world of emergency services, particularly in the fire and EMS world.  Today marks a change.  One, I’m about to give some very broad, generic “free” legal advice.  Two, I’m about to tell you NOT to volunteer.

Event medical standbys. At least in Texas, those fall into a massive loophole where they’re not subject to any regulation from the state. In Texas, transport providers (officially called “EMS Providers”) and “first responder organizations” are subject to state regulatory requirements.  Because event medical standbys don’t fit into Texas’s definition of EMS Provider or First Responder Organization, they’re completely outside the purview of our state EMS regulatory system.

These events always say “BLS only” or “CPR/first aid” but seem to recruit heavily from the ranks of EMS providers. If they truly only want “BLS” or layperson aid, why are they recruiting so heavily from EMS?  Simple.  They want EMS providers on site, but they’ve gotten some legal or risk management advice to not call it an “EMS standby.”  They think that by saying it’s only first aid that their liability will somehow be limited.  Truth be told, I’m not sure if it would or wouldn’t be limited.  But I know this much from law school — anyone that can be sued will be sued, both collectively and individually.  While you may not end up being found liable, I can guarantee that will not protect you from either a suit or the lawyer’s bills to represent you.  (Speaking of which, you do have your own EMS liability insurance to protect you and provide for legal representation, don’t you?)

This is the closest you’ll ever get to free legal advice from me. Just say no. You’re unlikely covered by any medical direction or protocols, which begs the question of what you’re doing there and whether you’re practicing “medicine” or delivering EMS care. And if all they want is “BLS” or first aid, why are they asking you to be there by virtue of you holding an EMS certification? I’ve helped at these events before and it feels very odd to be there without the ability to function at your certification level, assuming they’ve even verified your certification.

In the very best case, you’re probably going to be poorly equipped.  You’re even more likely to be expected to supply your own gear. And I will virtually guarantee that if something bad happens, you will be on your own. The worst part? Many of these events are for profit. Those that aren’t are usually run by nonprofits that have plenty of money for everything besides real EMS coverage. Many of these so-called event medicine companies have a business model based on you being an “independent contractor,” meaning that they’ll throw you to the sharks and claim that they had no oversight of you.  In other words, helping some of these events out for free as a “volunteer” isn’t much better than offering to drive Lyft or Uber for free.

If you truly want to “feel good” by volunteering, get a t-shirt, and/or be thanked for your service, there’s probably a volunteer service within an hour’s drive of you that would actually benefit from your volunteer hours. To me, it’s really ironic is how many paid firefighters/EMTs jump at the chance to work at these events and then say how volunteering “holds back the profession” and artificially lowers salaries.  If that’s the case, then it’s high time that we tell each and every one of these large public events that they need to provide EMS coverage just like they have porta-potties, trash collection, food service, and security on site.

Want to Volunteer?

Anyone who knows me knows that I’m pretty passionate about my volunteer work in EMS.  To me, it’s a wonderful way to give back and it’s a wonderful change of pace from my workday of moving contracts through the bureaucracy.

Those of us in the fire and EMS world hear a lot about the supposed shortage of volunteers.  Last week, I saw the irony of a state volunteer fire association doing a media outreach at the state capitol using trucks from a department that is primarily paid and doesn’t even have information on its webpage about volunteer recruitment.

So, in the spirit of an intervention filled with tough love, I offer you the following advice.

Want to join a volunteer fire or EMS department? Let’s talk about what happens.
1) Good luck finding the department online. If you do find them online, good luck finding an application.

2) If you do apply, you can expect some sort of committee process to see if you “fit in” with the prevailing culture of the department, which is probably dysfunctional.

3) If you have no interest in 80% of the fire department’s calls being medical, no worries. You don’t have to even get your first responder. But even if you already have your EMT or Paramedic, we will demand that you be a firefighter.

4) Training? What’s that? We’ll do training when we feel like it, on topics that only interest us, conducted by people with no qualifications. If you need additional training to maintain your certifications, that’s probably going to be on your own, with your own money.  But if the training sounds “cool,” you can fully expect that the connected members of the department will be travelling to it — on the department’s dime.

5) Equipment?  Yeah…. Here’s a t-shirt or two. We’ll issue you a radio, pager, safety apparel, and EMS equipment sometime, maybe — if we like you and/or you still keep coming around after putting up with us.

6) Leadership?  What’s that?  We’re likely run by a self-perpetuating group of insiders who are completely insular in our thinking and definitely don’t wear how anyplace else does things, especially from you, the new guy.

7) You’ll be on some sort of probationary process for a while, which will be a form of institutionalized hazing until we “check you off.”  Good luck getting one or two of the very specific training classes that you need to be released from probation.  We only offer those every few months at best.

8) We will continue the same things we’ve been doing for 40+ years, then wonder why we can’t find volunteers.

9) If we have paid guys, they’ll unionize and then claim that they can’t work with volunteers.

10) We will beg and plead everywhere for volunteers, show zero flexibility, and use that as political cover to put in another tax levy to pay for more unionized firefighters. Once we do that, we’ll then try to become an “all-hazards” department and get ambulances staffed by 18-25 year old firefighter/medics who want to do suppression only.

If you find a department where the majority of these thing don’t apply, stay there.  You’ve found a gem.

Brotherhood and Family

Everyone talks about the fire/EMS “brotherhood.”  Everyone says that we’re “family.”  Today, a few of my close online fire/EMS “family” were talking about how the term “brother” bothers them for some reason.

In the most abstract sense, I can get that.  “Brother” sounds like something you’d call someone in a religious order, a cult, or maybe the Moose lodge.  For some reason, I immediately picture Fred Flintstone and Barney Rubble in the Loyal Order of the Water Buffaloes.

But seriously, let’s assume that we want to be “brothers,” or to be politically correct and diverse, “brothers, sisters, and the pronoun you choose to identify with.” Well then, let’s really talk about what brotherhood and family mean in the fire/EMS world.

Brotherhood and family isn’t a t-shirt.  It’s not a cute slogan.  It’s not something we should do when it’s convenient.  It’s taking care of each other, watching out for each other, and yeah, it means we hold each other accountable too.

Brotherhood and family is checking on a partner after a rough call.

Brotherhood and family means taking the extra time to see a sick person in the hospital.

Brotherhood and family means that when you have a “brother” visiting from out of town, you spend a bit of time with them and maybe take them someplace local to get the feel of your home.

Brotherhood and family means that you take the time to mentor and train your station mates, even if both of you take time away from work to master the trade, because doing the job right matters.  Period.

One of my favorite incidents of brotherhood and family came when I did a ride at Station 11 in Clark County on the south end of the Las Vegas Strip.  As I was leaving, one of the firefighters gave me the station phone number.  I asked why.  He told me to call the station if I needed anything while I was in town because I’m “family.”

Brotherhood and family isn’t about hazing the rookies.  It’s not about creating a ridiculous paramilitary boot camp atmosphere.  And it’s sure as heck not about abusing the public trust or treating the public or our so-called “brothers” with anything less than respect.  And an IAFF sticker or a paid/volunteer status doesn’t mean a hill of beans about “brotherhood” or “family” either. It is always supposed to be about taking care of the public who implicitly trusts us to walk in their door at any hour and take care of them, hopefully like we’d take care of our family.

In other words, you can have all the slogans you want, wear all the t-shirts, say “brother” to everyone at the station, and eat all of your meals at the station’s dinner table as a “family,” but if you still have a toxic environment, inadequate leadership, a bunch of youngsters playing at being firefighters and medics, and a tolerance for inadequate service – then, no, you’re not my “brother” and you’re not my “family.”

The Semi-Regular Reminder on EMS Politics

Yep. It’s that time again. “EMS On The Hill Day” is just around the corner.  As we all know from EMS social media and the EMS “Powers That Be,” AKA:the usual conference speakers and the people who now provide consulting services to fix the messes that they created in the first place, merely showing up one day in Washington DC in a uniform that’s a cross between Idi Amin and the Knights of Columbus will magically fix all that is wrong with EMS.

 

I’ve worked in state government for years.  I’ve been a lawyer for years.  I’ve been involved in many political campaigns and involved in political parties.  I’m telling you — that’s not how any of this works.

 

We can fix EMS through the political process.  But it’s going to take more than one day per year in Washington DC.  Here’s what it’s going to take.

  1. MONEY.  Money fuels politics.  The reality is that politicians need money to get elected.  Money buys access to the game.  In other words, you can’t watch the game if you don’t have a ticket.
  2. All politics is local.  This famous quote from Tip O’Neill is so true. The Federal government has a limited role in the provision of EMS services, much of which relates to the role that Medicare/Medicaid funding plays. Local governments make the decisions on how to provide (and fund) the EMS system.  State governments typically are the ones who license and regulate EMS personnel and services.  And here we continue to think that the solution to EMS lies in Washington DC. State EMS associations need to step up the advocacy game.  Period.
  3. This is a year round sport.  EMS has to be engaged in the advocacy process year round.  Even in states like mine where the Legislature only meets every two years, there’s plenty going on in the “off season,” which is when interim studies happen and future legislation gets planned.
  4. It’s all about the staff.  Elected officials’ staff members are the subject matter experts and they help the officials develop their positions.  Their schedules are usually much more open than the elected official — get to know them and turn them into your ally.  In turn, they may well call upon you for input — and influence.
  5. The regulatory process matters. Getting legislation passed is great.  But oftentimes, the devil is in the proverbial details.  That’s why it’s imperative to be involved in the rulemaking process and in monitoring how the various regulatory agencies implement and interpret the law.
  6. Funding matters.  When you get funding, things happen.  If you want to fix EMS, fix the laws and regulations that reimburse EMS for being a transportation service rather than a medical service.
  7. Present the image of being professionals.  You want the elected official or their staff to consider you a professional they’d trust, not someone who looks and acts like they just got out of a clown car.

 

Of course, we all want the quick and easy answer to “fix” EMS.  We’ve been trying the quick and easy answers for years and here’s where we are.  Maybe it’s time we try what the adults have done to get their various professions a seat at the table in terms of funding and professional recognition from government.

Your Ride-Share To The Hospital

There have been several articles lately about the use of ride-sharing services like Uber and Lyft to get patients to the ER.  In one article, AMR is looking at a yet-to-be-defined partnership with a ride-sharing service.  Another article making its way around the EMS social media circles describes people getting a ride to the hospital from one of these services.

Of course, the schizophrenic nature of EMS raises its ugly head.  You’ve got some people saying, “About time.  These people don’t need an ambulance because they’re not having an emergency.”  And then you’ve got other people taking the other extreme position in EMS, namely, “If we don’t take you to the emergency room in an ambulance, you could become ‘unconscious, comatose, or dead,'” — just like the speech that most EMS providers give when obtaining a refusal.

Why should we be offended or bothered by this? EMS social media is constantly filled with complaints about how people should only use the ambulance for “real emergencies.” Now that people do, I notice some of the comments are about the risks of not going by ambulance. So, what’s it gonna be?
EMS can’t have it’s cake and eat it too. Do we want people to use us? Or do we want to discourage using EMS unless it’s a real emergency? And of course, how is the lay public to know what’s a so-called real emergency?

And as I’ve said more than once, we somewhat have ourselves to blame for everyone calling 911 for a ride to the emergency room.  Especially in comparison to the police and fire services, we’ve done a terrible job of public outreach and education.  Everyone knows who the cops and firefighters are and what they do.  Us?  Not so much.  It’s amazing how many people don’t even know that there’s a difference between an EMT and a paramedic and what they do. We’ve delivered one message well, perhaps.  That message is “If you’re having a medical emergency, call 911.”  When you combine that simplistic message with the failure of American/Western medicine to deliver medical care outside of a 8:00 AM – 5:00 PM, weekdays only model and end up sending patients to multiple specialists, labs, and imaging centers all on those same inconvenient schedules, is it any wonder that John Q. Public decides to “call 911 for an emergency.”  In other words, EMS and emergency medicine have become victims of our own success.  People know that if they need medical care, EMS and the emergency department exist and won’t turn anyone away.

What we really need are trained professionals who have the ability to assess and transport/refer to someplace in addition to the ER. And while we’re verbally masturbating over whether to be offended by this or an Arby’s ad, we’re not doing what we truly need to be doing — developing our profession into the role of a mid-level provider who’s able to deliver both the medicine and the patient in a manner that meets patient needs in the most cost effective way possible. And what emergency medicine needs to do is to actually read EMTALA, provide a “screening exam,” and refer non-acute patients to an alternative setting.  However, we need these prehospital mid-level providers and these alternative settings to exist in the first place.  I recognize there’s no funding stream as of yet, which is one of the major failings of the so-called community paramedicine initiative.  The truth is that you sometimes have to spend a little to save a lot.  That’s a truth that our government and healthcare payment systems have yet to grasp.

The Access To Knowledge

One of the greatest things about the Internet is that it has democratized access to information.  Most academic journals are available online, some of which are even available for free.  Wikipedia has improved, in most cases, to provide reliable information on most subjects.  There are plenty of other sites that provide scholarly level information out there.  Then there are sites like Khan Academy that make basic education in a variety of subjects available for free.  And if you can’t find the information online, you can order virtually any book online through retailers like Amazon.

In other words, you can have access to the same educational materials that train professionals in any field.  Want to learn gastroenterology?  The books used to train residents and fellows can be ordered online.  Want to learn engineering?  The materials are available online too.  Want to be an administrative lawyer?  Yep, law can be found online too.  You can find most legal codes online and with a bit of searching, you can even find the relevant cases too.

Here’s what none of these books will teach you.  They won’t teach you the mindset of how to think like a member of a profession.  The materials alone don’t teach the academic or professional discipline. Reading statutes, regulations, and cases may provide some insight on the law, but you won’t necessarily grasp the legal principles or reasoning, much less how a single law in and of itself interacts with all of the other laws out there.  Likewise, one can buy all of the cardiology texts out there and become quite knowledgeable about the heart while at the same time failing to realize that the heart is but one interdependent organ in an entire human body.

The democratization of information has done wonders for our society.  Yet, one of the biggest challenges is that mere access to information doesn’t necessarily mean understanding the information.  Nor does it mean placing said information into its proper context.  If you don’t believe me, look at the number of self-appointed experts who have “done their research” posting online. Cherry-picking from a discredited study doesn’t make you an expert on autism and vaccines. An undergraduate degree combined with a medical degree is where you learn to skeptically examine scientific claims, understand how the human body works, and put that knowledge together to treat patients. Likewise, merely cutting and pasting a statute that you found via Google doesn’t make you the next Clarence Darrow.  As much of a cliche as it is, “learning to think like a lawyer” is exactly what law school does — teaching legal research, teaching legal writing, and ultimately, teaching enough legal reasoning so that you realize that a case is rarely won by merely cutting and pasting a statute in and of itself.

Information is great.  Education is more than information.  Education is the process of learning how to process, synthesize, contextualize, and use the information outside of a vacuum. And that’s why there’s such a market for the coffee mugs that say “Don’t confuse your Google search with my professional license.”  Whether it’s an EMS certification, a professional engineer’s license, or a subspecialty in medicine, thinking that reading the books and journals on your own makes you the equivalent of a licensed professional is hubris to the point of danger.

How does this apply to my usual writing about my self-described expensive hobby of EMS?  Quite simply, our field has a fair amount of self-appointed experts in anything vaguely and tangentially connected to EMS.  While there are many in our field who worship at the altars of dogma, vaguely defined “experience,” and the even worse defined “how we do it in the field,” probably the most dangerous are so-called leaders in our field who routinely opine on subjects in which they have knowledge, but not the education to contextualize, synthesize, or harmonize the knowledge outside of what they just read and parroted.  If you don’t believe me, look at how many places immediately remove (or add) an intervention or medication based solely on one article that’s been making the rounds of the EMS community.

In conclusion, the summation of human wisdom in any field is rarely going to be found in a Facebook post or a blog post.  As the Romans would say, “caveat emptor.”  As Reagan would’ve said, “Trust, but verify.”

What Really Happened With The Proposed Sale of AMR

A friend and fellow blogger recently posted a blog where he lays the blame at the Trump Administration for the possible sale of AMR due to the possible repeal of the Affordable Care Act, AKA “ObamaCare.”  While it’s certainly trendy to blame President Trump, Republicans, and Russian hackers for everything (and I blame them for my breakfast tacos being fouled up), I offer a more reasoned analysis that lays the blame right back it should lay — at the feet of the management of Envision Healthcare, AMR’s current parent corporation.

In my opinion, Envision Healthcare and AMR engaged in two critical failures that continue to haunt EMS.

First, we in EMS like whatever is new and trendy.  If it’s on the cover of JEMS, a Facebook page, or mentioned by the right “EMS celebrity,” we jump right in.  Whatever is the newest trend, we embrace it and go all out with it. Envision/AMR jumped into community paramedicine and spent like drunken sailors on shore leave.  AMR spent significant cash on critical care classes for paramedics, partnerships with hospital networks and hiring a significant number of “celebrity” EMS physicians.  Yet nobody ever asked the simple question, “Where is the money to pay for community paramedicine coming from?”  Apparently, nobody found an answer to that.  In other words, EMS spends money like the stereotype someone who just got a tax refund check — they put new flashy rims on a car that barely runs.  In all honesty, there’s not even a commonly accepted definition of what constitutes community paramedicine – primarily because community paramedicine programs are designed to meet unmet needs in the local community.  In other words, the needs of one community aren’t going to be the same as the next town over.  And in keeping with the free market principles of the US economy, if there’s money to be made meeting a need, it’s likely that a business will expand to fill that need. The fact that nobody was in the community paramedicine market should’ve been a big, giant, huge hint — there’s not much money to be made in diverting repeat users of EMS.

Second, like I’ve mentioned before, EMS is ill-informed and poorly engaged in the political process.  From the get-go, there was no guarantee that the Affordable Care Act would provide a revenue stream for community paramedicine, much less EMS as a whole. Next, with a Republican takeover of both houses of Congress in 2010, primarily as a response to the enactment of the Affordable Care Act.  The fact that Congress controls the purse strings of the Federal government should’ve been a hint to Envision/AMR that the Affordable Care Act was in jeopardy.  Yet, aside from seeing pictures of “EMS On The Hill Day” where everyone dresses up in an EMS uniform where they do their best impersonation of Idi Amin, I rarely see EMS involved in the political or regulatory at the Federal level and virtually never at the state level.  Healthcare is one of the most regulated business fields out there and to fail to engage, especially effectively, in the political and regulatory process is professional malpractice, if not out-and-out incompetence.  Say what you want about a certain large private EMS company based in Louisiana, but those Cajuns have a government affairs team and in-house legal counsel — and those Cajuns were smart enough not to nibble on the “reinventing healthcare” bait that the Affordable Care Act dangled in front of private EMS.  They’re also profitable and return the investment to their employee owners.  Jokes aside, that’s pretty impressive in any business, much less the EMS business.

Blaming President Trump for the possible sale of AMR is like blaming the dealer at a craps table in Vegas for the bad gambling decisions you made.  In conclusion, Envision took a huge gamble based on a poor understanding of the business and regulatory environment that it plays in.  And sadly, Envision’s employees are possibly going to be the ones who have to pay for the loss.

 

Another Part of Being a Professional

Social media is the gift that keeps on giving for an EMS blogger.  It enables me to amplify my voice.  But today, it keeps pointing out something so obvious about why EMS still isn’t taken as a profession.

Plain and simple, part of being a professional, whether it’s nuclear engineering or being an EMT, means being responsible for your own learning. There are conferences, internet resources, journals (real journals, not trade publications), and even books that exist to expand your knowledge of all things about the delivery of prehospital medicine. Yet, there’s all too many in EMS who view social media as the equivalent of “phoning a friend” or “asking the audience” in a virtual EMS game show.  (Or maybe it’s the EMS Gong Show?)

While perusing EMS social media today, I’ve seen basic questions about how to recertify, how the National Registry exam works, and basic cardiac arrest management.  I’m far from the sharpest spoon in the drawer of EMS silverware, but I found the answers (and from reputable sources, no less) to these questions with a quick Google search. This leads me to one of several conclusions.  One, there’s a significant portion of people in EMS who are incapable of performing even basic research. Two, there are people who expect the answers spoon-fed to them.  Or three, they want someone to hold their hand and merely validate the belief they already hold.  None of these alternatives are promising for our profession’s long term viability.

As the bachelor’s degree has become the de facto standard for nursing, we continue to turn out a significant portion of so-called heroes who have no use for so-called “book learning” and believe that real learning only occurs on the “streets.”  And we wonder why the Los Angeles Fire Department is using nurse practitioners for community paramedicine?

Yelping The Eagles

Anyone who knows me knows that as much as I love EMS and law, I also enjoy good food and have a tendency to write reviews of good (and occasionally bad) food on Yelp.  This weekend, I’ve attended the Gathering of Eagles conference in Dallas.  Seeing as Yelp probably isn’t the forum to review the Eagles, I’ll blog my review instead.

Sum total 4/5 stars.

This was my first time attending the Gathering of Eagles conference, but it will definitely not be my last.  This is unlike virtually any other EMS conference.  First, the presentations are exceptionally short.  For many of us, it’s perfect for short EMS attention spans.  For others, the presentations are just enough to whet your appetite to dig deeper into the subject.  For some of those subjects, I’m probably in the latter.  Other subjects were brief enough so as to not lose my interest.

I also appreciated the value for the money.  For the cost of admission, you get two days of continuing education as well as continental breakfast, cold drinks during the day, and lunch both days.  I can’t think of any other conference that delivers that kind of value.

The other huge positive to Eagles is the accessibility.  Each of the physicians readily made themselves available to the audience for questions immediately after their presentation and around the conference.  In fact, at the lunches, the conference organizers made an effort to have an “Eagle” physician at each table.  The opportunity to talk informally — and learn — from some very respected physicians rarely presents itself this easily.

The final advantage to this conference is that the audience largely selects itself.  This isn’t a conference designed for the average provider.  It’s heavily science and research driven.  There’s quite the smattering of medical students, residents, EMS fellows, and physicians in the audience as well as senior EMS management.  There’s not a finer networking opportunity anywhere.

There are two caveats to this conference, although they’re nowhere enough to discourage attending.  First, with the heavy focus on research, there’s a strong emphasis on cardiac arrest and resuscitation.  In other words, dead versus not dead is easy to measure.  Second, the Eagles represent very large EMS systems.  These systems, by their very nature, are large urban systems.  Their models of care don’t necessarily easily translate to smaller systems where changes can be rolled out more quickly to a smaller number of providers.   In other words, not all that is presented here will be new to providers in more progressive or aggressive EMS systems. (Perhaps there’s a need for a separate conference with the physician medical directors of suburban and rural EMS systems.)

Having said all of this, I will definitely be back next year.

McDonald’s Applied To EMS

Nope, this post has zilch to do with EMS wages, so put those pitchforks away. Rather, I’ll ask a semi-rhetorical question.  Why do people stop at McDonald’s when they’re travelling?  It’s simple.  People know what they’re going to get and they like consistency. A McDonald’s in Boise isn’t going to differ all that much from a McDonald’s in Miami. By doing such, tourists may miss out on an incredible local diner. Just as likely, though, they could miss out on food poisoning by visiting a so-called local institution.

As of late, it seems that EMS is taking the McDonald’s approach to medicine where consistency is valued above all else. Again, as is the case with dining options, an obsession with consistency drives away exceptionally low standards and performance.  But it also seems to drive away high performance as well. And unlike a Big Mac, prehospital medicine in rural Nevada with long response times and limited access to hospitals is going to need to differ from a compact, urban center like Boston with multiple academic medical centers.

A good friend of mine has asserted that there’s a growing advocacy movement for mediocrity in EMS.  I’m not sure I’m ready to go that far.  But I do believe that the movement in EMS that pushes buzzwords is hurting EMS.

The buzzword movement pushes catchphrases such as metrics, data, standards, accreditation, “best practices,” and regularly misuses “evidence based medicine” in an effort to ensure a level of uniformity, consistency, and mediocrity in prehospital medicine.

The buzzword movement obsesses maniacally over cardiac arrest survival rates because dead/not dead is an easy metric.  Nevermind that cardiac arrest represents a very small part of what EMS does and that most out of hospital cardiac arrests are not salvageable, it’s an easy metric, so it becomes what determines “success” in EMS. Symptom relief and routing the right patients to the right care are nowhere near as easy to quantify, so these things (which EMS should be getting right) get overlooked regularly.

I’d much prefer that EMS systems focus less on consistency and compliance and more on excellence. From my experience in prehospital medicine, I’ve found that if you encourage medics (of all levels) to achieve a high level, most medics will do their best to reach it.  As the old axiom goes, a rising tide lifts all boats.

Instead of striving for consistency, I think it’s time for EMS to strive for excellence.  Even if we occasionally miss said mark, we’re going to improve rather than stagnate. Our patients deserve a commitment to excellence, not a commitment to consistency — which all too often has become shorthand for mediocrity.