Saturday, February 18, 2017

Trump Adopts Terrorism


Many have lamented the tide of decline of liberal democracy throughout the world, me among them. Clearly, the tide has moved into the United States. For a few weeks after the election I was willing to give some breathing room to Trump, to see how much was talk and how much would be action. My wife warned me that this was not a wise stance. But I found myself hoping. Denial is a primitive psychological defense, and I have long employed it. I was using it with Trump. No longer. The cabinet appointments have been horrible. And now the shock and awe of anti-immigrant terrorism has been overwhelming. I'm more than there.

Trump has a large following. Not a majority, and I'm hopeful that I am not in denial in thinking that it won't be such ever, but they sure have taken over. It's scary. I'm hopeful again not to be in denial in observing that Nazi control of Germany arose from weak governmental institutions, as opposed to strong American governmental institutions, and in observing that ours is the economics of prosperity rather than Germany's economics of Depression – although if Trumpism is to continue, the result could well be depression, it's true. I'm hopeful when I look at the world of the caudillos and observing that their traditions were less secure than ours, and that the gulf between rich and poor was wider, although understanding that ours is growing. I am cautious, but I'm hopeful.

But as Peter O'Toole defiantly declared in Lawrence of Arabia, nothing is written. They look like they are making a good try at it, riding the international wave. Executive Orders, the product of decades of executive strengthening, are providing the surfboard to ride the wave. EO's provide a narrow platform; it would take legislation to provide a motor on the board, and at this point we have to bless the tradition of the filibuster, a bulwark against tyranny of the majority. Bless you.

So what do you do if you only have a board and not a motor? Trump and the Republicans in their tolerance/support of him – I was going to say “Right Wing Republicans” but that has become a redundancy – have shown every caudillo inclination, and envy of the capacities of Putin to do what he wants with no troublesome restraints of separation of powers. Torture, victimization of minorities, bullying, suppresion of the press? Not a problem! “Do to them what they do to you,” not “do what is right,” is the mantra.

So, what you do is adopt the tactics of the enemy where you can, and get around Congress as best you can. You pick on those who are most powerless, you go for shock and awe. So, you can't deport all the 11.5 million undocumented immigrants without a lot of money and legislation – and you don't call them “undocumented immigrants,” but “illegals” – but what you can do is to terrorize them. Nothing wrong with terror, is there, if you use the standard of what “they” do to “us?” And within every society are goons who would love to do just that. ICE probably has them, they just are not wearing brown shirts yet, not yet.

Make widely visible raids, arrest random sympathetic people, mothers, saints if you can find them, put them in police vans, have children crying on TV, show the distress. Worldwide opprobrium? Bring it on – it's publicity. Defy, find people to defy. Instill fear, empower bullying. It's even better and cheaper than actual mass deportations. Terror works, it insinuates itself into the society, not just those at current risk, but those who view themselves as the next group.

Which is why I agree with everyone who says, “Resist!” Institutions and traditions are important, but in the end it takes people, specific persons, to act within those institutions and to follow those traditions. Today, even as I write this, I am at a committee meeting of the AAP, where we broke the ice by going around the table and saying what political success we had recently had, each one personally. Most people said they had been to the women's marches. Others said their kids had been there. I thought of my family's resistance, and then I noted our personal efforts to help some undocumented immigrants to get legal. Apparently all it takes in their case is money. We're happy to help. I'm thinking we should just put a sign out on our front lawn: “Resist!”

State-sponsored terrorism is a fearful thing. We're seeing the start. It's time to remember those who helped the Jews in Europe and pay back. It's time to resist. I'm still thinking that this evil wave will be meet by a far bigger counter-wave that strengthens us even more by current knowledge of how strong our democracy is. It's hard, seeing all the hatefuls in office. I just hope I'm not in denial.

Budd Shenkin

Monday, February 6, 2017

Hospitals, Health Care, Buggies, and Automobiles


I've been thinking a lot about the shape of health care, and working on a paper that is so tortured in its development, I'm beginning to think that it's a paper that will never be finished. Which is a shame, because I think the ideas are good, and naturally, because I love to see my name in print. But in a way it's not a shame, because what the paper is doing is forcing me to learn, which is I guess what a paper should actually be about.

The essence of the paper is that the shape of health care is changing, and what I see is that hospitals are trying to centralize care around themselves by buying up medical practices, and buying up skilled nursing homes and other allied facilities. You could call all this vertical integration (VI). At the same time you see lots of horizontal integration, with medical practices merging, hospitals merging, insurance companies becoming fewer and larger, etc. So there it is, lots of agglomeration, all in the service of protection of them that is and them that has. Rationalizing the industry? Somewhat, yes. But also protecting and aggrandizing themselves.

But, is centralization the best model? I think not. I think that decentralization would be better. We need lots of coordination of care, true, but VI is probably not the best way to get there, although coordination does need leadership, and that's hard to find in a decentralized system. But especially with modern IT and communication technology – if the government mandated that Electronic Medical Records (EMR) all be inter-operational, which it has to do, has to do – decentralized systems could work just fine. The decentralized system could be called the Center of Excellence (COE) system, because with all the competition for patients, each unit would have to work to become excellent. By contrast, if a unit is in a system like Kaiser, where all referrals are mandated to be intra-organizational, a mediocre unit is cushioned from competition.

Here are a couple of paragraphs in praise of COE from my paper:

The COE model envisions not VI corporations, but rather individuals and groups networked together by information and communication technology, rather than by ownership and overt direction. In this model, for instance, incorporating the model of the Patient Centered Medical Home (PCMH), the patient and the primary care provider would be choosing referrals among competing centers with varying combinations of cost and quality, be they large or small specialist practices, general or specialty hospitals or procedure centers, etc., rather then being tied into a mandatory network.

The more direct financial and personal connection to the patient may provide increased incentives for patient-centered care. Information in small units can be informal and immediately visible. Staff in smaller units specialize in only one enterprise with the skill that repetition conveys, and can focus on detail with unmatched attention. Hiring can be made appropriate to the specific need without the need to explain the job to HR. Talented and creative professionals and staff can exercise their particular abilities (e.g., computerized innovation) without corporate restraint.

The “caring function” may be easier to convey in decentralized settings, as patients may be more easily known personally by staff and professionals. Small units may have great flexibility to serve individual patient needs, whereas large companies may have relatively general and inflexible guidelines. (On the other hand, classically underserved populations might welcome general policies applicable to all, as they will not be discriminatory.) Staff and professionals can likewise benefit from enhanced non-bureaucratic personal relations.

Modern information and communication technology has given added strength to the decentralization argument. What had been a weakness – coordination and information exchange – is now easily effected by small offices as well as large, so long as the EMRs are inter-operative. If run well, a small practice can be exquisitely efficient with modern technology.

Anyway, I've got a lot more written about the details, so many details that it is probably pretty unpublishable, at least for this non-academic writer. But this is all prologue. As I lay awake this morning thinking about it, I had a thought that I liked. Unlike all the details of my paper that contrast the pros and cons of the integrated system vs. the pros and cons of the COE, this thought is succinct. And so appropriate for a blog post. Which, with no further ado, here follows.

What happens when an obsolescent institution seeks to direct an emerging institution? By this I mean:
the hospital has been the center of medical care for a very long time. It looks as though it has become very expensive, too expensive for the system as a whole. It looks also as if the locus and means of care is changing. It is becoming outpatient, with specialty units such as the outpatient surgicenter, and more and more elements of care can be lodged in outpatient settings. In addition, it seems that more and more “medical care” should really be “health care,” with attention to prevention, social determinants of disease, etc. And as we live longer and acquire more chronic diseases and we just get run down, residential facilities become merged with health care units.

So the system is changing, and the money still resides with hospitals, and they will use that money to perpetuate their predominance. But they are aware of the changes, and so they change their definition of their mission accordingly. They become not purveyors of inpatient medical care, but purveyors of health care in general. This is what organizations do. (Parenthetically, one of the reasons they do this is that the people in those organizations are loathe to give up on the organization, since the organization works, and the organization also confers onto those individuals a means of livelihood, and perks, neither of which is to be abandoned.)

So what are the consequences of this means of succession from one type of organization to another – where the obsolescent institution seeks to direct the birth of the emerging industry? One consequence is that the change is delayed by old habits that are not suitable for the new challenge. Another is that the change is wasteful, since old functions persist and are paid for. A third consequence is that the new organization has trouble being shaped into something that looks new.

What it reminds me of is the original automobiles. What preceded them was buggies, so of course the new autos looked like the old buggies, just with an engine behind instead of a horse ahead. The old stereotypes persisted and it took a couple of decades of persistent change until the Model T didn't look like a buggy at all.

I'd say that's the way we should look at the emerging health care system. It still looks like a buggy.

To really accelerate change, what's needed is a way for inventors to make gobs of money. Right now, everyone is (rightly, I guess) focussed on reducing the cost of health care. But it's hard to make money by reducing costs. When someone figures out how to make money with new institutions, that's when the buggy will come to look new and streamlined. Idealism is great and medicine has probably more of it than any other industry. But Schumpeter's fabled “animal spirits” come out when the scent of money to be made is in the air. That's what we are praying will happen with renewable energy – find a way for the animal spirits to do well by doing good. I'm thinking, same thing with health care.

Right now, the health care animal spirits are still looking around, to the on-line doctor (doomed!), to health monitoring by your smart watch (better chance here.) When the specialty hospitals take over, when money flows into primary care, when teaching is divorced from tertiary and quaternary care, when pharma is rationalized – that's when the reorganization will really take place. But while money is still with the bloated hospitals and academic centers with their gobs of money and administrators and grants and God knows where it all goes – while all that is still predominant, the future will still lie pretty far ahead.

Anyway, that's what I've been thinking.


Budd Shenkin

Saturday, January 28, 2017

A Democratic Strategy


A quick note to the Democrats on strategy. Democrats need to be wary of embodying Will Rogers' declaration that “I'm not a member of any organized political party. I'm a Democrat.” My fear is that Democrats will be over the top in resistance rhetoric by firebrands, but unsure how to use the fuel of mass protests and popular revulsion at Trumpian policies. That Democrats will be running helter-skelter, not knowing how to oppose as a group, how to find spokespeople to hold to a line of thought and rhetoric. That Democrats will be confused by the welter of targets and so hit none of them cleanly, will not be able to vote as a bloc as the Republicans could, will not be able to decry an Administration the way the Republicans did when they said Obama excluded the possibility of consultation and finding common ground. My fear is that the “reasonable” Democrats will be mamby-pamby. My fear is the “Democrat” will become a term of scorn.

It shouldn't actually be very hard. You just have to be clear on your goals. The overriding goal should be: to kill dead the Republican Party. To do to the Republicans nationally what Governor Pete Wilson was able to do in California when he committed his party to suicide by backing the anti-immigrant Proposition 187 in 1994, and thus lost California for Republicans for at least a generation, maybe more. It was as momentous as LBJ's loss of the South, which he did knowingly, and for which he should be regarded as a Profile in Courage. Now, nationally, we just need to collaborate with Trump and the Republicans as they have set out in their Death March.

The Republican Party is not your father's Republican Party, it is a body double inhabited by forces alien to the American tradition. They are basically racist – look how they treated Obama. They are against safety net programs at all. They are against the environment. They are against abortion. They are against one person one vote. On and on. As a party, they deserve to die. Trump should be regarded as a useful idiot in killing the party dead.

The mission of the Democratic Party, should they choose to accept it, then, is to tie the Republican Party as closely as they can to the Trump Administration's obnoxious, hurtful, antediluvian policies, in an effort to kill them dead. Their mission should not be to kill Trump dead – he is an abnormal transient who won't last. But the Republican Party is the real threat.

Concentrating on personalities can be helpful sometimes, but the Democrats need to find the main themes, name them and number them, and then tie every specific policy to the main themes. Gingrich did something similar in 1994 with his Contract For America, and it worked. And for every policy, don't concentrate on Trump and Bannon and their proposals – concentrate on the Republican Party – are they behind it? Will they allow it? And make sure there are 48 Democratic votes and voices opposing.

Others could construct the list better than I, but here's a vision of it. Antediluvian social policies – anti-abortion, anti-contraception, anti-feminine in every aspect. The culture war redux – it wasn't settled, apparently anymore than racism was. Antediluvian – that's theme #1.

International economics is pretty clear – Trumpian trade wars are ill-thought out, theoretically indefensible, and will fuel higher prices on goods and perhaps a recession. That's theme #2.

Combative international relations, every day another example, needless conflict, dangerous conflict, money-losing conflict, job-losing and price-increasing policies, outdated analyses, isolating steps. Paranoid – theme #3.

Anti-environment – theme #4. They want to worsen pollution.

Racist, homophobe, etc. - #5.

Anti-safety net – #6.

Inside dealers who make themselves rich - #7.

Theft of public lands - #8.

And so on. Make a list, identify each issue that comes up with that list. So to make it clear to people.

Then, the Democrats have to understand the use of the hammer. No one ever drove a nail through the plank with one blow. You have to hammer, hammer, hammer until the message is received and internalized and ready for repetition again and again. Hammer it home again and again.

As for tactics, well, there is enough stupidity around, God knows, make fun of the fools. Have Bannon impersonators walking Pennsylvania Avenue, have sandwich ads walking the streets with “Want a contract – stay in a Trump hotel!” emblazoned. Conflicts of interest are easy to understand.

And then, work with Trump on things he is for and that will embarrass the Republicans. Call the bluff. Introduce a trillion dollar infrastructure program that is paid for by taxes on the rich – paid for, paid for, paid for. Hammer it home. Paid for. Fiscally responsible. Let the Republicans try to make it profit, or not paid for, and look to the theme list. Make it understandable, and discombobulate the opposition.

The manner in which it is done is important. We need firebrands like Elizabeth Warren to hold in the Left, even if she is getting carried away with her celebrity, as I think she is. She's right, she's smart, she is useful, but she doesn't appear centered. But what we really need is the lower key leaders, smart, intense, brave, centered, persistent, believable. Leaders whom we can believe will care for us, the electorate, the citizenry. Someone who can say, “What they are proposing is just ridiculous. These people are idiots.” You don't have to be respectful, you just have to be centered. Idiots – that's got to be a major theme.

Tennis great Bill Tilden said you can beat someone by aiming at their weakness, but if you really want to humble them, attack them at their strength. My choice would be to show the electorate how intellectually bankrupt Paul Ryan really is. He thinks he is smart, but he's not. Topple him.

The Senate will be a center of resistance, and I think Shumer is up to it. We'll see. But to my mind, where we are really going to find leadership is in the states. Most states have gone over to the Republicans, but not the major ones. I can see how those governors, of California, Oregon, Washington, Minnesota, New York, Massachusetts, Virginia, and others could form an alliance and agree on model legislation, for climate and environment, for instance, and healthcare, and immigrant status, etc. They could pass legislation and invite other states to join them. The state elections could then be referenda on whether or not to go down the path of California, Oregon, etc. See which other states want to join the informal union of progressive states.

If the federal tax burden declines, the progressive states could capture the – have the wealthy and corporations pay more to the states and less to the feds, and make better use of the money in the states than the feds would. California will send less money to Alabama; well, we can use it at home. Too bad for Alabama, but maybe the underclass would rise there; one can only hope.

The agenda in the states might bring good candidates out of the woodwork. If you look at the quality of state candidates in elections, it seems abysmal to me in so many states. No wonder we lose. The political class is far from top drawer. We need a new elite to get those candidates fielded and the agenda drawn. This positive agenda could do it, while the Senate would be busy painting the Republican Party as what it is, theme by theme. Let the Senate be the killers, and the states be the builders.

Be centered, imaginative, united, and disdainful of the fools who are in momentary control. Retool the team. Make sure everyone understands that these are the bad old days of the future. Maybe that's the overall theme – the future will see this four year eruption as the bad old days that preceded the good new days, as the reaction overcame the momentary rupture of progress. But only if we prepare. And only if there are leaders to lead, and only if the feckless are labeled as such.

I believe in the moral imperative of optimism. I keep repeating that to myself. I'm hammering it home.

Budd Shenkin

Saturday, January 21, 2017

Who You Gonna Fear and Loath?


What we have to fear is not Trump the Autocrat, but Trump the Beard.

This conversation that Bob Reich had with a former Republican congressman friend, reproduced below, casts light on where fear and loathing should fall, and it's not on Donald Trump. Yes, this blog has visited his boorishness and other unattractive personal characteristics, as have others TNTC (that's medical-speak for “too numerous to count,” as applied to white cells in a urine specimen that has been spun down and concentrated and looked at under a microscope, and is presumptive evidence of infection. “TNTC” was used, it should be noted, well before email and texting,when medical records were hand-written and succinct.) Yes, he shows signs of wanting to be an authoritarian, but he'll never make it, not in a hundred years. He doesn't have what it takes, and the country's institutions and political culture are too strong for that to happen. And yes to every other shortcoming everyone has noticed. But is he the real threat?

No, the real threat of Trump is as Trump The Beard. Here is Bob's post (I know him a little bit, hence the “Bob” moniker, just showing off....):

I had breakfast recently with a friend who's a former Republican member of Congress. Here's what he said:
Him: Trump is no Republican. He’s just a big fat ego.
Me: Then why didn’t you speak out against him during the campaign?
Him: You kidding? I was surrounded by Trump voters. I’d have been shot.
Me: So what now? What are your former Republican colleagues going to do?
Him (smirking): They’ll play along for a while.
Me: A while?
Him: They’ll get as much as they want – tax cuts galore, deregulation, military buildup, slash all those poverty programs, and then get to work on Social Security and Medicare – and blame him. And he’s such a fool he’ll want to take credit for everything.
Me: And then what?
Him (laughing): They like Pence.
Me: What do you mean?
Him: Pence is their guy. They all think Trump is out of his mind.
Me: So what?
Him: So the moment Trump does something really dumb – steps over the line – violates the law in a big stupid clumsy way … and you know he will ...
Me: They impeach him?
Him: You bet. They pull the trigger.

So, who is to be feared? The new Radical Republican Party, which replaced the old GOP several elections ago, and certainly bears little resemblance to the GOP of decades ago, is a fundamentalist party. There is a lot to argue with about how government currently acts – in that, Trump's disdain has some merit. There is a lot of swamp that could be drained. I won't go on to detail the shortcomings and borderline corruptions (and outright corruption) of government from both sides – read about Fanny Mae and Freddy Mac if you want to get sick to your stomach about Democrats. A lot of reform of government, now that's something tasty to reflect upon.

For all his bluster and ill will toward the many, I bet that the real burr under Donald's butt is the superior class who has captured government, those who hold Donald in low repute even though he has more money than most of them (we assume), and the rank mediocrity of so many governmental officials.

I can't help mentioning once again that the apotheosis of governmental inefficacy was the Obamacare website disaster. And then how Leon Panetta viewed it: “They relied on the bureaucracy for that? For something that important, you have to go around the government!” And that's a Democrat speaking. One had to ask, why wasn't the A Team involved from the beginning?

(That's unfair, too. The VA health care system is head in low repute, but I just read an article in JAMA that shows them to be cutting edge on how they are improving their system – they have the mechanism of improvement down pat. http://jamanetwork.com/journals/jama/article-abstract/2598276.)

But a reform of government by the Radical Republican Party is as chimerical as repeal and replace. The the Radical Republican Party is really the party of increasing privilege and blaming the victims. Trump has the banner in his hand and marches forward, while they use him as they can, then take over and defend the wasteland they have created.

But, personally, I think they are a doomed sect. There's only so much havoc they can wreak. (For “wreck” vs. “wreak,” see: http://blog.oxforddictionaries.com/2016/01/wreak-havoc-wreck-havoc/) And after that, they will scatter to their various infamies.

In health care, if they really wreck the ACA, the next step is, inevitably, single-payer. I love ironies in history! I gravitate to them, my mind seeks them out, they come to me I can't help it. Here's the deal:

The Democrats wanted to establish a health care program that made health care a right for all Americans. They built upon the already-jerry-built structure of Medicare, Medicaid, Children's Health Insurance Program, community heath clinics and Federally Qualified Health Clinics, Rural Health Centers, private health insurance, county clinics and hospitals, federal state and local support, etc. To get enough support for the ACA, they used a Republican structure, originally from the Heritage Foundation, then from RomneyCare in Massachusetts. The Democrats went Republican.

But then, that wasn't good enough for the Republicans! They had to have their say! So they repealed without being able to replace, wreaking havoc in the health care market, causing not only popular distress but institutional distress among hospitals, insurance companies, counties, providers, etc. And then with a new Democratic administration, one not tied to the old ways and with a huge surge of popular revulsion of the Radical Republicans, the people just said: Medicare for All. Thanks to the Republicans. You can't make this stuff up, you can just watch it unfolding.

So, if the Radical Republicans are wolves in a wolf's clothing, let them do what they will, and let them, like the sheep they are, be led over the cliff by a blind one, and may the blind ones at the head of the line be named Paul, Mitch, and Mike. We'll be cheering their precipitous demise.

Budd Shenkin

Sunday, January 15, 2017

Indian Summer



“Make the diagnosis!” – as my medical journals would challenge the reader on page 39 or so. Shouldn't be too hard, for most doctors. First noticed last Friday on the flank of a 75 year old man, about three inches below the left axilla, the patient discovered the lesion by inadvertently touching it when toweling off after a shower, indicating that it was raised enough to be palpable. The pigmentation was variegated within the lesion with a deeply pigmented, almost blue section, and the border was irregular. On very close inspection, there was possibly a small halo of depigmentation, perhaps slightly bluish.

Meanwhile, although the cold and wet weather has come this year in the real weather, in our septuagenarian lives, it seems like Indian summer. “Indian Summer.” Why it's “Indian,” no one seems to know, not even the internet. But everyone agrees on how sweet it is. As a teenager growing up in Philadelphia, I thought that autumn was the best season, sunny and not too hot and not with the Atlantic seaboard humidity of spring and summer. I lived a 15 or 20 minute walk away from my high school, and I remember thinking as I walked across the empty, treed lot at the corner of Montgomery Avenue and North Wynnewood Avenue, that fall would be my favorite season if it weren't for the fact that winter impended, when the cold and winds make you pull your jacket closer around your neck as you walked along the long curve of Montgomery Avenue in the early dark on the way home. That's where the fall weather is headed, but “Not yet!” proclaims Indian Summer. “You got more, man!” And you enjoy it, you take off your jacket, you eat outside, you throw a ball around and take a walk and say how warm and clear it is, and tell each other how lucky you are. You know it will recede, and you hope it stays longer, just a little longer before you have to cover up. That was the way it was in Lower Merion in the 1950's, and that's the way it is for us today in our 70's. Indian Summer is to be relished.

Here in Berkeley it's now January and the weather is cold and rainy, but thankfully not windy, but we are covered up. We know we need the rain, so it's good and welcome and we don't feel oppressed, at least not yet. We've had our health challenges (see http://buddshenkin.blogspot.com/2011/08/welcome-to-neurosurgeryland.html, of course), but when I'm asked how I am, I answer: “Vertical!” Verticality is as sweet as Indian Summer, and you never know when your own personal clouds and wind will come.

Nowadays we know a lot more about our health than we used to know, just as the weather-people on TV and even our smartphones have satellites to consult. It wasn't Mark Twain, but Charles Dudley Warner who said that “Everybody talks about the weather but nobody does anything about it.” That's probably still true of weather. A storm appears up in the Arctic and we follow its course down the coast, and maybe it will weaken and maybe it will continue on down, but we can't do much about it except prepare for the effects. That's where the weather and health differ; in health, we detect and then we act. Maybe there's something we can do about it, sometimes not, but more and more, there's something. Still, sometimes things just come out of the blue and there you are, you're never completely sure what will come and when.

So when I was toweling off and my hand strayed to an area I don't generally look at – you could say I'm not vain so I don't look at myself, or you could say, given my excess mass, that vanity is the motive force for not looking – and I took the picture you see above to Make The Diagnosis, I wondered if an arctic storm had just appeared. I know enough about skin lesion that I wasn' just worried, but alarmed.

Fortunately, four years ago I had been responsible enough to have switched dermatologists from a contemporary to a younger doc. Jason Fung was a new derm in town and had been, humblingly, a schoolmate of my kids at Head Royce School. Good guy, active, extroverted, chatty, efficient, forward looking with a scribe at his side. His survey of my skin had revealed nothing troubling, but he now had the visual record on me. When I called his office with “ a suspicious mole,” they offered me a spot that very afternoon. I couldn't take it because I had to take Ann to the doctor, but as it happened she had a routine appointment at his office four days later so I was lucky enough to get a spot ten minutes after hers. Ann thought my prompt appointment was evidence of special treatment, but I said “suspicious mole” was code for “get me in NOW.” Not only good patient care, but malpractice avoidance dictates some actions in practice. Like, for pediatricians, “he has excruciating testicular pain.” A ball can die if it is twisted on its stalk, and you'd rather not have that, and neither would your insurance carrier.

I told my friend Stu when I saw him at the gym that I was going in to be checked for a suspicious mole and he said, “It's probably nothing.” Which is what Ann had said, although she had said to be sure to get it checked right away. I hesitated to take solace from their opinions because I know wishful when I hear it, and I had seen it close enough to know it was a problem. But you never know. I can be alarmist.

So on Tuesday Ann went to her exam room to have her stitches out and I went into my exam room and took off my shirt, joined by young lady scribe asking the questions on her script. Then Jason burst in asking about Allie and Nick and Brian and Sara and even Peter and … whoa! “That looks funky!” said Jason as he caught sight of the lesion. No more small talk. I was surprised that it had been four years since I had been in for a survey; hadn't felt that long at all. And I don't know when my last physical was and if Jim had looked carefully at my body when I saw him – there's enough to talk about without something you don't know is there. So how long the lesion had been there was unknown, just less than four years, and probably much more recent.

It's at least making a neoplastic transition, he said. It might not have made it to melanoma yet, but it's pending. In less than five minutes it was out and in a prep jar on the way to pathology. I thought that the speed of extraction reflected his efficiency, but neither of us wants that thing in my body one more minute than necessary. It was Tuesday and he would call me Friday on my cellphone. He gave me a roadmap – either local excision in his office, or over to UC for tracing drainage to the nodes and wider excision, no more talk, let's see. Let's not prejudge, he said. But I heard his voice and I knew it was scary. He said that he knows it wasn't there four years ago because he had checked everything before he had come in to the exam room. It wouldn't have been his fault. I do the same thing, look back to what I could have done, etc. Was I culpable, is always my question of myself. Guilt is always alive in the mental workings of the Budd. But how long had it been there? We couldn't tell. Sometimes it takes time, and sometimes they just explode. Path would tell us how deep it went – less than 1 millimeter is the best – whether the excision had gotten it all with a good margin, and how the cells looked, aggressive or not so much. In any case, we'll be seeing each other more in the coming days, said Jason. I like Jason, so I told him I would enjoy seeing him.

I was curiously calm. Fatalistic, or in denial? I know I'm really good at denial. Or, you could say I'm really good at being in the moment. Nah … I deny. Ann didn't understand that it was dangerous until later; I think she was in denial, too, but maybe not. But anyway, I figured, say it's really malignant. What would happen? Scan the whole body for metastases? Where does melanoma go? Brain, for sure. Maybe liver, everything goes to liver. Bone? I dunno; lung goes to bone. I would rather not have brain metastases, with seizures and seizure meds, etc. Rather not. Hard way to go.

But what I thought was, then I would know how I would die, unless something else came up. I've never known how I'll die – my heart's always been pretty good. My mother died of breast cancer. Maybe cancer. Who knows how Indian Summer ends and when? I've always figured, somehow, that I would go to my 80's; maybe that was wrong. I've said for some time now that I had taken care of my major responsibilities. Kids up and out. I've got enough money so that it will be a great help to them. Ann needs me. We're in Indian Summer together, walking together. I thought about my funeral. My book club would come, my poker game, my medical friends, Bob and Adele, my sibs and their kids, Larry and Michael and Marjorie. Stephen. Stu. David and Joanna. SOAPM would send flowers. I had always wondered if any patients would want to come. Maybe some, but how would they hear? Some of them love me, that's what I need to know. As they say, it should be a good time, I'll be sorry to miss it. What would Nick do, my estranged but still loved son who works for the FBI?

My financial affairs – I'm pretty simplified, which is good. If it looks touchy, I'll sell the condos and make it simpler. Everyone should be OK. Need to make final adjustments.

It will be a different life from now on, if the melanoma is a threatening one, knowing more and having the blanks filled out. Shorten the time line. I've been getting into really good shape and made a new lower weight target. Keep that up? What about the French? Continue with that? Do the paper on healthcare I'm working on, or give it up? I had lunch with my friend Richard, with whom I'm working on a project, and I found less enthusiasm if I would have to devote the final days. Would hang back on that. Maybe watch more movies, which I am already doing somewhat. Somehow, less pressure. Not much reason to do anything except enjoy yourself. While waiting for the curtain.

I knew it was a melanoma. Jason said let's not prejudge, but I knew. “Funky lesion” doesn't make it into the diagnosis books, but then, it's taken until this year for Northern California (actually Berkeley-Oakland) “hella” as in “that's hella good!” to make it into Merriam-Webster. And medicine is even more conservative. I never want to be an “interesting case,” and I'd rather not have a “funky lesion.” I was already thinking about immunotherapy, hoping I wasn't going that way. But prepared to do it, too. Making sure that others don't get too upset. At least my parents have died, so they won't get upset. No one's indispensable, and everyone thinks when someone gets sick and dies, at least it wasn't me. Checking the ages in obits. A diagnosis takes the curtain back a bit, knowing from what and closer to knowing when.

What if it was in brain already and very aggressive and I hear, “maybe six months.” What would happen then? Well, it's coming sometime. Get the kids straight,make sure no one gets too upset. Provide for Ann, that will be hardest. Have to work with Sara.

We'll just have to see. I told Jason, yes, we're planning to go to Maui for two weeks starting next Friday, but forget that, we go all the time. The medicine comes first. Maybe I'll have to ….

On Thursday morning Ann had just finished with her yearly physical and we were walkingdown 30th Street past Summit to the car when the phone rang. It wasn't Friday yet, but I saw on the phone that it was Jason. He hemmed and hawed for a minute, and I thought, Oh, shit. But then he got to the point. Yes, melanoma. OK, Jason, not great, but that's not the crucial info. Why was he hesitant. Waiting. But … good news! He should have started out saying “Good news,” but I guess he was still hung up on the “melanoma” part. But, only 0.9 mm deep – hoping to be less than 1 mm, and there it is! Just ducked in under the limit! Excision margins – clear! State of cells – not aggressive yet! So, if you had to have a melanoma, this is the one to have, he said. You bet! He said that he would schedule me for a wider excision by the lady who does them at his office. OK by me! In fact, how about tomorrow, Friday? You bet! 1 PM in Lafayette office? Sure! Get this done.

No need to change any plans – go to Maui, go on cruise, Indian Summer continues! Yessir! Worry dispelled. Looked it up on internet finally, and stage 1a, 97% chance of non-recurrence. I'll take that with gratitude.

So, what people say sometimes after they have been seriously ill and they have refocused on their lives is, I won't say I'm grateful for this, but it did me a lot of good. I'm wondering now, I can't say I'm grateful for this scare, but it was only a scare, but scary enough so that I started traveling in the shady land instead of just imagining it, and I know I'll be there someday, so can I say hey, maybe this was the best of the worlds, that I can change my life for the better and still didn't have to be sick. Can I do that? Or maybe I can just realize that my Indian Summer is going just fine. We'll see what I think.

Carpe diem, man, carpe diem. Do as much good as I can and enjoy every single day, even the cold, rainy ones. I just have to wonder, will this rain ever stop? They say we're mostly out of the drought. Hope so. 

BTW -- here's what it looked like ex post facto.  A lot better out than in....




Budd Shenkin

Wednesday, January 11, 2017

Warriors Redux


Here in the East Bay, home of the Warriors (even though they are not called the Oakland Warriors, and we are worried they will be called the SF Warriors soon instead of remaining Golden State – Oakland gets no respect!) we have been viewing the Warriors a bit quizzically. Last year and the year before, there was no hesitancy. Enthusiasm and possessiveness -- Our Warriors! -- was pervasive. This year, it's more like interest, rooting, hoping – but less possession, maybe. A little less.  They've changed. Change is the way of the world, and capitalism has invaded sports, and not just in naming stadiums but in defining the sport itself, and we understand that “sports is in the entertainment business” and we understand we understand, but that understanding doesn't always penetrate through to feelings.  You never step in the same stream twice, but often you think you're doing it, and other times you know you're not.  This year, we know we're not.

So I'm watching the games, with interest, with cheering and appreciation, but sometimes not to the bitter end. The other night I watched the Memphis game and they were coming apart at the end and KD (Kevin Durant) was playing some hero-ball, which is seldom fun to watch and for which he was loudly called out by Dramond Green afterwards which took some newspaper and coach explaining, and I just went upstairs while they were still ahead thinking they could well lose. Didn't want to see it. Didn't stop me from tuning in to the Miami game two nights later, I'm still interested in how they evolve as a team, but it's not like last year.

I have made a new friend, Benj Demott, from New York, who publishes First of the Month (firstofthemonth.com), whom I met through my good friend Bob Levin. Benj follows basketball, and is now a Warriors fan – good for you, Benj! He said he was preparing an article on the Warriors, so I sent him my feelings. I think men talk about sports the way women talk about boyfriends, btw. Here is what I wrote him, slightly edited:

Here's what I think about the Warriors.  I think that last year was a special year, a magic year, to use two poor, very over-used adjectives.  It was unusual and distinct.  What happened?  First of all, there was the streak -- no, wrong.  First of all, there was the championship of the year before that put a target on their back.  They hadn't had to play San Antonio in the playoffs, and Kyrie and Love were out for Cleveland, and Charles Barkley was on their back, so it was questioned.  Good thing there was no Russian hacking.
And then there was the parade through Oakland.  I was there with my son and granddaughter (the latter only for a while - she was 5).  It was something else.  Klay Thompson said, I didn't know there were this many people.  He said, I mean, they come to the games and they're great, but I didn't know that there were so many people that we mattered to, or something like that.  The parade had a role in ushering in the next year (which, if you're getting confused, was last year, 2015-16, when they lost to Cleveland in game 7 of the finals.) There was something surprising about the championship, and the parade itself was kind of home brewed, and very Oaklandish. Ours.

Then when the new season started -- 2015-16 --everyone was out to get them, so there was no "usual regular season game" for them.  Every game was a semi-playoff style game.  It started with The Streak, and the Warriors took the bit in their mouth and accepted the challenge.  That was unusual.
Then, there was Curry.  Unusual season for anyone, Charles saying no one can keep that up, and the shots kept falling, and his drives were something to see, and the passes.  Stats for threes were "unbelievable," or would have been not long ago.  Now, they are barely believable.  It was a crest.  Everyone on the team wanted him to shoot.  So, that was quite unusual.  There was also Klay's 37 points in a quarter, which I loved in real time.
Then after the unprecedented opening season streak of 24 straight wins there was the season record to go for, so every game counted on that score, too.  Again, Kerr asked them, do we want to go for it?  They said, yeah, we do, and they did and they made it and every game counted and every other game was close, it seemed, and everything broke their way, even the injury to Barnes that let Brandon Rush flourish.  So if you were a fan you couldn't miss a game.  Even though everyone knew this might mean they would peak too early.
And then the goddamn refs.  Charles and even Oscar Robertson said they would know how to stop Curry, rough him up.  That disappointed me about both of them.  I'm nearly ready to throw O off my all-time 5, except I don't believe in making teams according to behavior.  Anyway, that's what the refs let teams get away with.  If you saw Curry without the ball, you saw fouls, you saw rough stuff, and the refs -- who continue to blow so many calls it makes you think "there might be something going on" -- seemed complicit with Charles and O.
Then there was the refs and Dramond.  OK, perhaps immature, but hitting him with all the technicals was really bad, and basically at the end, they cost the Warriors the championship, between Curry not being a full strength which was partly regular wear and tear and partly roughing up, and Dramond out for a game.
And, of course, that team was a real team with some longevity together.  This, being a real team, going crazy on the bench when someone did something good, feeding Klay the ball for 37, laughing and poking each other, warming everyone's heart.  And Kerr had cultivated the second team, Barbosa, Iguadala, Speights, etc.  The year before (2013, I guess), I had gone to a game early on and watched the second team lose a big lead down to where the Warriors were 9 up before he put the regulars back in, maybe against Phoenix.  I thought what I was seeing was Kerr grooming the second team, and by the end of the year they were there.  And then the next year they were even better.
So now, it's different.  There is no streak to work on.  They are a target, but it's not like last year's target, and the team has different guys on it, with Barbosa and Rush and Speights gone from the second team, and Bogut from the first, and Barnes although I don't mind his leaving.  The regular season games seem like regular season games.  The talent is terrific, and there are challenges -- I see too much hero-ball from KD, and they have to say to him, hey, there are other heroes on this team, and we all play together all the time.  So they're good, great even, but in the making of a new team.
I personally think they'll go all the way.  But it will be Warriors #2, not the Warriors as they were, winning again.  It's a new team winning.  They're great, and I still love them.  But this year I'm not nearly so hesitant to book travel and be away for a while.

Budd Shenkin

Tuesday, January 10, 2017

Finding a Strategy, and Why Streep Isn't It


OK, Meryl Streep is a wonderful actress, a very smart and eloquent lady. But I think her Golden Globes statement, while striking and eloquent, was a strategic mistake. And here's why – because it puts style over substance, and not everybody agrees with putting down Trump's style.

Trump is gauche. He's crass. Trump sounds like and often acts like he's from the construction yard, from Queens. Despite his wealth, he seems to act in a way we could see a working class person acting. He's not dumb, but he's not nuanced. He's gruff. He doesn't have the manners one associates with wealth, let's put it that way – the way Romney acted and sounded.

But think of the people who voted for him, the “undereducated.” Many of these people are just repelled by the pretension we see in the classes with money. And I mean, repelled. The Sheryl Sandberg's speak to a certain, privileged class. How to relate to the nanny and keep her away from your husband can be a major concern.

I don't know where the populism comes from in Trump. People are often loyal to their origins. Sports stars “give back” to their home towns -- Damian Lillard comes back to Oakland High and dedicates a gym; Dramond Green goes back to Saginaw . My wife's ex-husband isn't an athlete, but his loyalty to his family origins led him to establish a non-profit that gives computers to poor families in Oakland.
Others are quiet about their loyalty. The Millionaire Next Door kind of person just keeps on living his or her life and piles up the money and then gives it away at the end. Why change a winning game, they figure, I guess. They're happy as they are.
Could Trump's populist attachment be sincere? He himself comes from wealth, but he also comes from Queens, and he has liked to hang out in the construction yards. Maybe, or more probably he just found it in his search for fame and adulation and improvised. Maybe he grew up somehow hearing the Borsht Belt and that's where he got his shtick. Trump is actually faux risen. He acts as though he is giving it back to The Man, as he cheats and bullies his contractors. Then he acts like the avatar of getting back to his roots.

But the fact that he is an imposter isn't the point right now; I just got diverted. The point is, he has carried it off. In his manners and his social defiance and his strong id, he has made many of that oppressed class identify with him. That's the point. He channels resentment, and when Meryl and Hillary and the pathetic Jenn Palmieri try to point out his grossness, the oppressed class responds – up yours! You who have it made, you the ladies who lunch, we're going to listen to you? Crotch grabbing and poor taste is your concern – we're concerned about our jobs and getting paid and our husbands lack of prospects. Don't complain to us about how you might feel disrespected, thank you very much.

This fight over manners is self-defeating. The more the fight is over manners, the more separation of classes there will be, and the more perception of hypocrisy.

Instead, I think one just has to accept the Jacksonian manners. Let the reaction be what it will be. Instead, one has to concentrate on policies. Trump's and Ryan's and Republican policies are atrocious. Don't think people are so dumb they can't see that. It just has to be laid out and explained. And it would be best if it were explained by someone with a working class sound. Bernie Sanders' background isn't working class, but his gruff manner has a sound that resonates to many. It's direct, it's low-pitched, it's intentionally simplifying to make the point. (It's an open question how simple Sanders actually thinks it is – Barney Frank told me he thinks Sanders isn't very smart, but Frank is so partisan....) I'm not suggesting that Bernie be the spokesman, but plainspokenness is essential.

In telling the truth as simply as possible, it can be personified in Trump and the hateful Ryan and then the billionaires who turn out to be hateful. Here's how they are hypocritical and screwing you! Have someone use the word “fucking” and be caught by a “secret open mike.” “Those fucking bastards are screwing the people – how the hell are we going to make that case so that people hear and understand it?”

Find the messenger – and it's not Meryl Streep, and it's not Elizabeth Warren. Warren is eloquent and smart, she even has that humble background, but she's from Harvard and it shows. It needs to be someone like Harold Hughes from Iowa used to be. Or patrician FDR, who knew how to relate, because he really was a man of the people in Warm Springs, Georgia, where he invited everyone into the water with him, to help each other with their polio.

To be simple: Stick to the issues, man. And find a voice of the people. Obama was pretty close; it's too bad he didn't after-sell. Find someone who can, now.

Budd Shenkin