Wednesday, February 19, 2025
Doctors, Mothers And Daughters, Death and Caring, Writing
Monday, February 17, 2025
To Thwart A Coup
My son Peter sent me this podcast from Ezra Klein.
https://youtu.be/K8QLgLfqh6s
Here is my response:
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Friday, February 14, 2025
Will There Be A Credible Resistance?
I think a lot depends on how the Dems can organize themselves in resistance. Leaders must be allowed to emerge. Congressional Dem leadership now is old and abysmal. They need a War Council, and regular Addresses to the Nation analyzing what's going on, and how it's a coup, an autogolpe, or a revolution, and pointing out in detail what they're doing and how they're lying about it.
Who can do this? Buttigieg can explain it, others are eloquent and passionate, but they are all either backbenchers, or sometimes governors. They need to organize themselves as The Democratic Resistance, and challenge the rest of the Dems to follow and join them, or not. That would capture the country's attention, give media somewhere to go, and set up for the lawsuits which are already progressing, and most importantly, for 2026 elections. Each Dem would have to choose, are you an active resister, or not? Through this, the candidate for the 2028 election, should there be one, would emerge.
What they obviously cannot do is to rely on their current congressional leadership. Schumer and Jeffries might be effective insiders, but Schumer is an awful public speaker -- reads his remarks into the rostrum -- and Jeffries struggles. Their task is to hold the Dems together within their chambers; swaying the nation is not in their remit.
Anyway, that's my take. Even this might not work, because SCOTUS has already been captured, so many other courts (Aileen Cannon, Judge S. in Amarillo, etc.). This War Council, plus the states, with active AG's and Governors in the blue states, are the last hope. Popular movements, demonstrations, etc., I would think would only arise with good leadership explaining what is happening and gathering adherents that the people could rally around. Remember what Allard Lowenstein had to do -- find a candidate.
Budd Shenkin
Thursday, February 13, 2025
The Fruits Of Aging
As you get old, you accumulate wisdom.
As you get old, you make more mistakes, or continue with the old ones but they get worse.
Which is it?
I think it's both.
It's just like it's always been - you try your best, and try to forgive and get others to forgive your mistakes.
Sometimes it works.
Monday, January 20, 2025
How The World Is Organized -- The Trump Model
What is going on with Trump's view of the world? He wants to stop supporting Ukraine, is very iffy on NATO, hasn't said much about Taiwan, but wants to flex on Mexico, Canada, Panama? What's up?
I can't review all the different ways of organizing the world – not my area of expertise – but clearly we have had empires (Rome, China, British), and we have had configurations of independent states with balanced power(Europe after the Council of Vienna). We've had a system of international laws that recognize countries' boundaries and strive not to interfere internally in their affairs (never really respected). We've had a dual-centric world – USSR vs. USA in the Cold War. We've had systems where armed interventions are supposed to be abjured – post WW I. And so on. Some would say the world has always been organized by strict power, and ideas to stop war and rule by recognized rights is most a modern attempt. But as I say, it's not my field.
So, as far as I've been alive, the world has been dominated by the thought that we should have a universally recognized system of laws and avoid wars. At least, that's what I've seen. Now we have challenges to that, as the Chinese seem to say that this so-called system of rights and respect is hypocritical, and just hides the continuation of the long era of Western domination. And now, it seems, we have a new view, probably a view that would be called “realist,” from Trump.
That view seems to be this: We know that Trump has fancied himself a realist of the thuggery of the world. He has idolized gangsters. He thinks it realistic to understand that countries kill people, they just hide it. The states are all hypocritical, Trump thinks, they say one thing and do something else. The words are on the surface, but it's something else beneath.
He liked to hang out at construction sites at his father's buildings. The working class sees power and people being compelled, not cajoled and persuaded. He himself likes to bully. A lot. So, I think he sees the natural order of the world being based on power and ruthlessness. That would mean that strong states bully weak states, especially nearby ones. This leads to a multi-centric world where regional powers dominate their neighborhood. This is an ancient situation, where transportation and communication was none, or months, or years. In those days a regional power would think of themselves as a world power, because their worlds were small. Nowadays, we know better than to think ourselves isolated, but with the threat of nukes keeping world powers at a distance and enforcing limits, no one should really aspire to world domination, but they can aspire to regional domination.
Who is this reminiscent of? Well, that was the world Hitler envisioned. Let the Japanese dominate the East, let the USA dominate the Americas, and let Germany dominate Europe. Hitler couldn't see why others didn't agree. That's also – relevant to Trump – the view of the Mafia. Let one group dominate Buffalo and don't bother them, cooperate when possible. We keep Brooklyn and Queens, let others have New Jersey. We can compete in new areas, like Las Vegas, but we won't threaten the home territories of the other families. And in both these cases, Hitler and the mafia, force is the dominant influence.
So that's the way Trump sees the international organization. That's why he thought Putin's invasion of Ukraine was brilliant. He surely understands Xi's determination to take Taiwan, with Hong Kong already digested. He thinks it's just weak for the US to allow nearby weaker states to be independent – why don't we dominate them the way the USSR dominated Eastern Europe? It's our right, because we're strong. Mutual respect of borders and sovereignty is stupid and weak, to Trump's understanding.
And what do the leaders of these blocs do? They make sure they get themselves rich. Putin is reportedly the richest man in the world. I hear that he has a deal with each oligarch that he, Putin, personally, has a 50% interest in each of their enterprises. That's why Trump idolizes him. Of course! He's the strongest and that's what he deserves. He's due it. That's exactly what Trump thinks he's due. It's the way of the world, the true order, not this made up stuff about mutual respect and ideals. Realism.
So, no mystery. We don't interfere with the way other dominant states rule their area, and we don't care what they do. Human Rights? Gimme a break. That's made up stuff by the Sunday School crowd. Me, I'm a realist, Donald the Realist. He was the strongest in his family and he dominated them, he was the strongest in the Republican field, and now he's the strongest in the country. Don't give me that stuff about right and wrong.
For starters, Donald no doubt wants a 50% personal interest in the Panama Canal, and a 50% interest in each Canadian energy company.
Why not?
Budd Shenkin
Friday, January 17, 2025
Humanistic Care - Defining and Implementing
Medicine is supposed to be humane, kind and caring – to be humanistic. Yet both patients and doctors complain that our current system lacks precisely that quality. Patients complain that their doctors often don't get to know them well, that when they are sickest they are cared for by strangers in non-patient-centered teams, and that they get lost, neglected, and delayed in a complex system. Doctors complain about burnout, alienation, even moral injury, as they, too, miss the human connection with patients and regret the systematic obstacles they face.
Two prominent influences for this decline are, ironically, the great advances in Biomedicine (BioM), and the ubiquitous business methods utilized in medical care organizations. The proliferation of specialists, procedures, and studies has presented organizational challenges, and efforts to achieve systematic efficiency, productivity, and profit have often given short shrift to the necessity of warm human interactions.
The loss of Humanistic Medicine (HM) is not inevitable, but it must be understood if it is to be protected and reintroduced to the system. First, HM should be defined. Second, we should examine its composition, to decide if HM is central to the mission of medicine, or if it is only a frill that might as well be neglected. And third, we should define some necessary steps to implement HM in practice.
Definition
The standard definitions of HM cite the actions of the doctor as the central factor. One example: “the physician’s attitudes and actions that demonstrate interest in and respect for the patient and that address the patient’s concerns and values. These generally are related to patients’ psychological, social, and spiritual domains.” Another source cites the “Three C's”: “(HM's) main components(are) 'comprehension' of the patient's narrative and importantly – emotions; leading to 'compassion' and a 'commitment' to act trying to help as much as possible.”
These definitions have two shortcomings. First, they are process-oriented rather than outcome-oriented. The desired outcome of HM is that the patient should feel known as a specific individual, not a cog in a wheel or as an input, and should feel cared for and cared about. Second, even though the definitions do well in describing desirable physician HM actions, they are too narrow, because they ignore the contributions of other personnel, and the system of care itself.
A corollary to the outcome definition is also important: the benefits of HM accrue to the givers of care as well as the recipients. Humans feel great satisfaction in giving to others. Doctors, other caregivers, and even system planners and managers benefit from treating patients with high-level HM. In fact, it can give significant meaning to their lives.
The Content and Extent of HM Services
HM is effected both by the organizational system of care and the individuals within the system. The system's design and functioning let patients know if their needs come first or last. For instance, are appointments made easily and timely, or (for instance) is a patient with a new cancer diagnosis made to wait in psychological anguish many weeks for a first appointment? If it is the latter, that system could be accused of HM malpractice. Likewise, is the length of an appointment tailored to individual needs, or is every patient wedged into the routine average time of a visit? Is continuity of care respected, and are various specialists and tests all coordinated in a patient-centered way, is there always someone for the patient to turn to for personal help, or are patients left in the lurch? These are just examples of the myriad of organizational HM factors. Organizational leaders, system designers, software designers, human relations departments, managers and others are in charge of all these items of HM.
All service industries have to accommodate customers, but medicine is a special service business. No other line of business addresses “customers” so intimately, with such emotionally-laden, high-stakes and sometimes complex and dangerous pathways and decisions. The pressure on patients and clinicians can be immense, as they deal with life, death, disease, disability, anxiety, and anguish. Patients and their families need to be cared for with an intimate knowledge of their emotions, backgrounds, and beliefs, as the standard definitions point out. Patients don't just need a reliable sales representative as with other businesses, they need someone whom they can trust with their most precious possession of life and health, someone with deep understanding and compassion and skill and reliability. Figure One shows why HM is central to the medical mission, not peripheral. Any system design or educational effort or practitioner neglecting that special responsibility of caring in medicine is in violation of the medicine's central mission, to cure when possible, but to care always.
Requirements to Implement HM Services
If HM has weakened, which seems to be the consensus, what is needed to strengthen it? Most importantly, the priority of HM in health care organizations and medical schools should be promoted to stand beside profit and BioM excellence as an equal top priority. This takes leadership, but it also demands support in the ranks, most prominently from doctors, other caregivers, and patients, those who experience HM most directly.
Instead of the current lip service, this high priority must lead to sustained attention and devotion of resources. Managers must be given the task of maximizing HM to the extent possible. They must learn to implement HM-friendly conditions, developing processes that are more patient-centered and less factory-like. Electronic communications should be an asset for HM, not an additional barrier. Measures of HM must be developed, even if they are based on process rather than outcome, so that they can stand beside the current measures of productivity, financial profit and RVUs, both of which notoriously ignore HM, and in fact classify time spent on HM as waste. Business management techniques are valuable, but the goals of medicine must be recognized as different from typical businesses.
Likewise, medical education must specifically target HM teaching, especially in clinical training, where HM teaching has often been assumed rather than specifically included, and where HM has often met the counterforce of an “informal curriculum” that discounts HM. BioM is relentlessly taught and tested, appropriately, but HM needs its own emphasis in imaginative ways that suit it, and take it out of the shadows. Every medical school typically has many HM-friendly personnel; they need to be mobilized into active contributors to a coherent HM effort.
Finally, incentives for practicing strong HM need to be harnessed. Inherent idealism in students and practicing doctors is considerable, but in addition to idealism, HM productivity and excellence in teachers, practitioners, care teams, and managers needs to be recognized, celebrated, and paid well.
Conclusion
While it is complex, HM is definable. While BioM is of ultimate importance in curing, the caring provided by HM is a worthy partner. Humanistic care is not a frill, it is essential to the medical mission.
All organizational change is difficult, and strengthening HM will be no different. But since the basic elements of HM are known, the task is mostly one of reengineering rather than of basic research. With a readjustment of priorities and with devoted effort, it should be well within our current capabilities to re-humanize medicine. Where there's a will, there's a way.
i. Gilsdorf, JR. No one in charge. N Engl J Med 2024;391:974-5.
ii. Dean W, Morris D, Llorca P-M, et al. Moral injury and the global health workforce crisis. N Engl J Med 2024;391:782-5.
iii. Branch WT, Kern D, Haidet, et al. Teaching the human dimensions of care in clinical settings. JAMA 2001;286;1067-74.
iv. Schattner A. The essence of humanistic medicine. QJM: An International Journal of Medicine 2020;113; 3-4.
v. Hundert EM, Hafferty F, Christakis D. Characteristics of the informal curriculum and trainees ethical choices. Acad Med 1996; 71; 624-42.
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Challenges to Caregivers in Humanistic Medicine |
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Patient relations |
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Doctor-Patient Relationship |
Understand choices available, apply which model is appropriate to each situation and patient. |
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Role of the doctor |
Knowing how to integrate professional demeanor with personal and professional authenticity |
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Doctor flexibility |
Understanding the history of relational expectations, different national and cultural expectations, and how relationship expectations have changed over time, with patient independence emergent, and paternalism in decline |
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Doctor flexibility |
Understanding how to adopt different styles for short-term and long-term patient relationships |
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Understanding patient needs |
Understanding the power of projection, how patients need to feel they are in good hands |
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Patient variability |
Understanding both the commonality of patients, but the differences that culture and finances and other circumstances present |
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Communication |
Knowing how to elicit and communicate information and feelings effectively and sensitively |
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Emotional distance |
Be conscious of what the distance is for each patient and family, know how to be close and available, but still objective, know your own needs and capacities. |
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Empathy |
Know how to be truly empathetic from one’s own experience and practice, and know how to communicate it. |
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Caring for |
Be conscious of and know how to fulfill patient need for emotional support, and for continuing positive monitoring of medical progress and offer guidance. |
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Boundaries |
Understand and adhere to boundaries of patient relations |
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Power relationship |
Understanding the power relations between doctor and patients, and not using it inappropriately |
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Respect |
Treating patients with respect, as a patient with disease, not “the thyroid in 208,” not “a fascinoma” |
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Navigation of difficulties |
Knowing how to handle difficult and provocative patients. Understanding clinician anger when patients don’t fulfill sick role properly. |
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Severe Disease |
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Deliver bad news |
Knowing how to and when to give bad news, such as a diagnosis of serious disease, returning cancer, untreatable condition. |
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Caring for seriously ill patients |
Knowing how not to shy away from very sick people |
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Organizing clinicians |
Knowing how to integrate into present care physicians and caregivers who have treated the patient in the past, especially PCPs. Coordinating specialists with consistent voice for patients |
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Organizing team care for seriously ill patients |
Assigning roles, appreciating all team members, coordinating actions, sharing understanding of actions and goals |
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Switching from cure to care only |
Knowing when to stop treatment and switch to palliative care, involving and listening to the patient and family, but showing leadership |
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Caring for “incurable” patients |
Knowing what to do when there is nothing to be done, how to be there with the patient |
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Cooperate with family in terminal disease |
Knowing how to comfort families of the dying |
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Confronting death |
Knowing how to process death, the family's feelings and your own - understanding and accepting the natural course of life and death |
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Making sense of serious illness |
Knowing how to employ narrative medicine to help give share a meaning for the patient’s life |
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Making sense of serious illness |
Knowing how to adapt to belief systems and values of the patient to put life and death in perspective |
Thursday, January 9, 2025
The Heart of Scientific Progress
It's a little crinkly as a photo, but this is the image of my article, taken from the post a few days ago, as published in the East Bay Times/San Jose Mercury.
And also the on-line version:
Opinion: The heart of scientific progress beats for all of us
It takes money, time and patience, but constant investment in medical science helps millions of people to thrive

I’m in my 80s now, so I remember what life was like in the 1940s and 1950s. In those days, heart attacks hung like the Sword of Damocles.
They took the lives of so many, and few knew what to do about it. Several times, neighbors called my dad, a neurosurgeon, to their houses, only for him to find someone dead in bed. At the news of the death of another friend, Joey, who died at age 39, my parents could only shake their heads.
Philanthropist Mary Lasker and U.S. Sen. Lister Hill of Alabama took the long view. Seeing the health problems that beset America but also seeing the beginnings of medical science progress, in 1955 they persuaded the federal government to vastly expand the National Institutes of Health, targeting research on heart disease, cancer and stroke, the major killers of Americans. Over the following decades, the NIH and other agencies have spent billions of dollars on in-house research and on grants to hospital and university researchers. Amazing progress has ensued, benefiting us all.
Here is one personal example. In early December, my next-door neighbor David Levine, a 71-year-old law professor in apparently good health, felt some discomfort in his upper back. He wisely visited his primary care doctor. Suspicious of a heart problem, she sent him to cardiac stress testing.
The stress testing was abnormal, which led to scheduling an angiogram promptly. As David nervously anticipated his angiogram, I reassured that this is now just routine, the welcome medical situation of “another one of these” rather than the dreaded, “Hmm, this is challenging.”
The angiogram would have seemed otherworldly to my parents’ generation. The cardiology team made a small puncture of David’s right radial artery and threaded a catheter up into his coronary arteries. They were surprised to find that the right anterior descending coronary artery was 90% blocked in two adjacent spots, a very dangerous condition.
They inserted stents and transformed the arteries from 90% blocked to 0% blocked in just a few minutes. David was under waking sedation for the 90-minute procedure, answering questions from the surgical team and watching continuous images of his beating heart on a monitor as they operated.
After the procedure, the interventional cardiologist told David he was only a few months from a heart attack — the 1950s scenario. Instead, just four hours later, David was on his way home to resume his family and professional life. We laughed together at the wonder of it all.
David’s story is repeated daily for people in every walk of life. Did Lasker and Hill dare to imagine this future? We must be grateful to them and to the researchers and practitioners who developed such techniques, the professionals who care for us, and to the leaders who continually invested on behalf of subsequent generations.
Was it too expensive? We can ponder government spending priorities, but as Lasker said, “If you think research is expensive, try disease.” It takes money, time and patience, but look at the results for millions of people.
With a new presidential administration assuming power in Washington, we hope that they honor the vision of Lasker and Hill and keep investing in scientific progress. Let them not be seduced by the vision of headlines trumpeting mindless “efficiency” and claims of “money saved.”
Let’s hope we won’t be led by those who know the price of everything and the value of nothing. What could be of higher value, after all, than what we have just experienced?
Dr. Budd Shenkin is a physician in the East Bay and a graduate of the Goldman School of Public Policy at UC Berkeley, where he is a member of the board of advisers.