Picture This

In Joshua Rothman’s piece about image manipulation in the digital age, the photo-forensics expert Hany Farid discusses “various milestones in the history of image manipulation” (“Afterimage,” November 12th). Among the examples he cites is “the transposition, in a famous photograph from the eighteen-sixties, of Abraham Lincoln’s head on the body of the slavery advocate John C. Calhoun.” This is indeed a vivid example of image manipulation, but it is not photographic. I’m an associate curator in the Department of Photographs at the Metropolitan Museum of Art; several years ago, while doing research for the exhibition “Faking It: Manipulated Photography Before Photoshop,” I viewed the images of Lincoln and Calhoun at the Library of Congress and discovered, to my disappointment, that these works aren’t photographs—they’re mezzotints, a type of engraving. For printmakers, transposing a new head onto a body in an image was a common labor-saving device. Given Farid’s reputation as an exposer of fakes, this seems like an error worth noting.

Mia Fineman

New York City

On the Record

Atul Gawande provides a thoughtful analysis of the extraordinary changes that electronic medical records (E.M.R.s) have brought to medical practice (“The Upgrade,” November 12th). As a doctor, I’ve seen that the primary incentive to adopt E.M.R. software comes from insurance companies, not medical providers. This is particularly problematic for a doctor who is still trying to figure out a patient’s diagnosis. In the case of someone with chronic pain, for example, a doctor might order laboratory tests to try to solve the problem, or to treat symptoms for which the cause is unclear. But, with the advent of E.M.R.s, insurers often refuse to pay for these tests if there’s not already a clear diagnosis. To avoid wasted hours on the telephone with representatives from insurance companies, doctors assign unambiguous diagnoses to the patient’s E.M.R. rather than record what they actually believe. This process degrades the medical record. To improve E.M.R.s, we must develop a system that allows doctors to acknowledge the ambiguity inherent in any medical practice.

Michael D. Lockshin, M.D.

New York City

Gawande refers to the process of rectifying glitches in the E.M.R. system as “mutation and selection,” the key factors in Darwinian evolution. Given that Darwin emphasized the random nature of mutations, I think it would be more accurate to describe the mechanism of change, in the examples that Gawande cites, as Lamarckian: the inheritance of acquired characteristics. When Neil Malhotra, a neurosurgeon interviewed in Gawande’s story, worked to improve the E.M.R. system at his hospital, he refined the software based on whether functions proved to be useful or useless. This might be akin to “natural selection,” but the success of a particular function is hardly random.

John S. Torday

Torrance, Calif.

E.M.R. software is usually written by coders who have no understanding of how it will be used, purchased by hospital employees who have no understanding of the specific work for which they are purchasing it, and supervised by administrators unfamiliar with the actual procedures of staff. There is a misguided belief that mistakes can be prevented by forcing detailed completeness in even the most trivial task. No one’s judgment is trusted; no category on the form can be skipped. In my experience, the best doctors’ notes tell a clear story about a person. With E.M.R. software, there is no training for providers on how to write a useful and succinct note, and there is enormous administrative pressure to include every conceivable detail about a patient’s visit, in the misguided hope that this will decrease liability claims and improve billings. The resulting notes are much too long to read when clinical decisions are urgently needed. There is only one solution: train users to exercise their judgment and permit them to skip irrelevant information. A less fussy record will permit better care.

Daniel L. Johnson, M.D.

Menomonie, Wis.

Seeking Approval

In his piece on democratic political institutions, Yascha Mounk neglects an institution that has caused considerable havoc—an election system that restricts voters to selecting only one candidate (“Too Much Democracy,” November 12th). One alternative—approval voting—allows voters to mark their “approval” for multiple candidates. The candidate with the most votes wins. Take the 2000 Presidential election, in which Ralph Nader received ninety-seven thousand votes in Florida. Polls show that most Nader voters preferred Al Gore to George W. Bush. If Nader voters could also have voted for Gore, he likely would have become President. In the 2016 Republican primaries, a crowded field of candidates divided the vote in several races, enabling Donald Trump to triumph with only minority support. Polls indicate that John Kasich was, over all, more acceptable to voters than Trump and that he probably would have defeated Trump if approval voting had been used. Earlier this month, voters in Fargo, North Dakota, decided to adopt approval voting for future mayoral elections. It’s time that we institute this simple, practical reform in other elections.

Steven J. Brams

Professor of Politics

New York University

New York City