Thursday, November 1, 2018

The Midterms and the Dem Organizational Problem

On the afternoon of Halloween, I went over to the Goldman School of Public Policy at Cal, where Dean Henry Brady, President of the University and former Arizona Governor and Secretary of DHS Janet Napolitano, and famous Professor Bob Reich opined on the coming midterm election. Henry discussed the four-part split of the Republican Party and the difficulty of their negotiating their conflicting interests. Napolitano discussed the closeness of the coming race and her optimism on the Dems capturing the House. Reich discussed his pessimism over the gerrymandering and voter suppression of the election, how both Democrats and Republicans had overlooked the problems of the non-college education whites over decades and the economic hardship and resentment this had caused, and how the underlying issue of the election was now authoritarianism vs. democracy, all of which left him pessimistic. He doesn't see the Trump election as an aberration, apparently. In an effort to be optimistic, all agreed that the generation of the students in the room were more engaged than any they had encountered in years, and Napolitano observed that actions and reactions are the way of politics.

When Henry read my question to the panel, which was "how come the Democrats are launching such small bore issues for the election?" Reich smiled knowingly and glanced sideways at Napolitano, who replied that the issues weren't small bore at all, health care is important, but one has to tailor arguments to each locale.  That latter is true, but the national organization's role should be to set a tone and some general perspective in a skillful, inclusive way, and not just rerun "protect Social Security" for the millionth time.

At the reception afterwards, I spoke with Napolitano, whom I had not met before. I asked her about Diane Feinstein's decision to run again at age 85, observing that I imagined that she could not really answer the question. She said that she liked Diane, that she was surprised that she had run again, and then wanted to say more, but then agreed with me that she really probably should not say anything else. She asked me what I thought.

I told her that I was appalled by DiFi's decision. If she had retired, there would have been many competent applicants for her job; it was a rare chance for someone younger to move up. I said that I thought it reflected the Democrats' misunderstanding of the task at hand. Their task is to find the younger leadership within their ranks and nurture it. If one views the Democratic party as an organization, what organizations need to do is to assure their vibrancy as they move forward, to identify, to nurture, and to promote the talent for leadership within their ranks. Think of it as a corporation. There, competent leaders would be conscious of the need to find and promote the talent, and not to let it languish. They would look out and say – “Look at her, over there, down in the ranks. She's great! Let's move her up! Let's get her more experience, more authority, develop her!” That's not what we hear from the Democrats. Instead, the gerontocracy keep their places as long as they can, and aspirants for higher office are left to fend for themselves. That's one way to let leadership emerge, but to my mind, not the best way. It's too chaotic, and it doesn't select for competence.

Then, probably thinking that this was the perfect opportunity to drill for an opinion from a random but well-informed Democrat, she asked me what I thought about Pelosi. Happy to be asked, I phrased my answer as artfully as I could. I told her that Nancy had done a wonderful job in her career, and she should be honored for it. But the Congress is a complex organization. There is an inside job and an outside job. Chuck and Nancy might do a wonderful job on the inside operations, but as Trump has shown, there is a crying need for doing the outside job, of speaking to the country and leading its thought. Trump is good at this, and the Democrats are Little League compared to him. They need to compete with him better on the battlefield of public opinion. This requires new leaders; we need to refresh the screen. Obama reflected that after eight years he was required to leave, and although he regretted it (and although we certainly have come to regret it,) he thought it was a good thing. Organizations need to refresh. So, to conclude, I think it's time for Nancy to move on.

And in fact, that's not enough. The Dems need to consider there whole operation in terms of fostering leadership. I had coffee a few weeks ago with six-term Congressman Jerry McNerney, who now represents the Stockton area. Jerry is a scientist, which makes him a rarity in Congress. He would be a natural for leadership of one of the scientific committees, energy or environment. But because of the seniority system, which the Republicans have abandoned but the Democrats have not, Jerry will be forever mired far down on the committee membership list. This sort of process makes Congress a dead place for leadership development; the best will abandon it or be unhappy and un-influential. This is the description of an ailing institution. And it seems to me that the Dems don't seem to understand that this is their problem. If the Dems are conscious of their decades long losing, they might consider the need for leadership, and they might consider how their organization is sabotaging their ostensible efforts to win.

Or, to put it differently, if I have to listen to Nancy Pelosi, Chuck Schumer, or Tom Perez orate on TV once more, I'm going to scream.

Napolitano told me she agreed with me. Then I told her that if the election went badly, as Bob Reich feared, then the entire leadership of the Democratic Party should resign, just as would happen in the UK after a failed election. Just as I said this, Reich came up to us, gave me a little startled look as he heard my peroration, smiled, and then thanked her for coming to the session, and she replied that it was very refreshing for her to get out of the President's office and to participate, and I excused myself since I had been monopolizing her time and she should really mingle more.

Before I left, I also told her that while I understood Reich's pessimism, I had found a source of optimism within the recent tragedies. Look at the reaction of the congregation in Charleston after the murders there, the reaction at Margerie Stoneman Douglas High after those murders, and in Pittsburgh after those murders. The deep understanding, the dignity, the bravery, the spirituality, the commitment to democratic action and the better angels of our nature displayed at all three areas (all of them disenfranchised, note – youth, Blacks in the South, and urban dwellers,) the principled and civil way they spoke out against Trump, spoke of a deeper spirit of America that will not be trampled over. We might have a difficult row to hoe for a while, a large part of our governing body has shown itself to be craven and corrupt, but in the end it is the spirit and traditions of a people that are the determinative forces, and I have faith in America.

I do.

Budd Shenkin

Monday, October 22, 2018

Lying Is The Message


Marshall McLuhan taught us to be metaphysicians. Don't just be reactive to the content of what is said or shown; instead, sit back and look at what's happening. The text is not the only information transmitted by the communication. Look also at the implication of what is transmitted and how it is transmitted. Look at the affect (not “effect,” “affect.”)

I continue to be amazed at the amazement of commentators on Trump's lying. I was amazed myself at first at Trump's shamelessness as he lied, and put it down to how he had learned to conduct his business as a flim-flam man. I thought that he didn't realize that he couldn't get away with it on the more visible stage.

Then I thought that he found out that he actually could get away with it, just as he had gotten away with it in business, so why not continue? It was like there was a bug in the system, that it didn't catch lies, and he was taking advantage of it. Amazing, but understandable.

But now I've gone one step further in my understanding. It's not just that people believe him. Some do, but lots of other supporters don't. But not only don't those who know he's lying not mind, they even rather enjoy it. That's the amazing thing.

Trump is not stupid; he's ignorant, cruel, sociopathic, and many other terrible things, but he's not stupid. What Trump has figured out, and I agree, is that lying itself works in his favor. Lying isn't a bug, it's a feature.

Why is it working as a feature? Trump is contemptuous. He is contemptuous of morality, of ethics, of compassion, of experts, of respectability, of science, of truth, of women, of the poor, of pretty much everything except money. Lots of people in our society are resentful, and they can find many targets to express their resentments. All societies have these elements; it's always there waiting to be exploited. You could even say that the success of societies could be measured by the percentage of the population harboring significant resentments. The most troubled societies in the most troubled times are the most vulnerable to those who would mobilize resentments. We are apparently at one of those most vulnerable times.

When Trump lies, when he glories in his lies, when he struts with his lies, he says to the world, “Fuck you! Don't tell me what the truth is, I'll tell you what the truth is! And I'll have millions of people shouting with me, so you can shut up with your truth, with your pretensions that you know better, that you are better and more elite than I am, that your rules rule, that you can tell me what to do. Just fuck you!” The resentful feel as one with him as he struts his contempt.

So, the WaPo can tote up the lies – they are amazing, I have to admit, how does he do it? – and commentators can still protest at them, as they should. But I am amazed myself that we don't hear people who have figured it out, who understand that it's a feature not a bug, and who understand it's one of the keys to the visual Presidency, a Presidency based on appearance, on aggression, on strutting, on pretension.

Lying with impunity, and being celebrated for it, is the dream of every miscreant schoolboy. What a triumph!

Budd Shenkin

Wednesday, October 17, 2018

How Would Hyman Roth Have Handled The Khashoggi Murder?

From Godfather II:
 
Hyman Roth: … Just one small step, looking for a man who wants to be President of the United States, and having the cash to make it possible. Michael, we're bigger than U.S. Steel. … What I am saying is, we have now what we have always needed, real partnership with the government.

If you simply think of the Trump Crime Family Administration as the Hyman Roth Administration, you're pretty close to the truth.  “Public interest” and “public service” – that's for suckers.  Imagine the cynical smirk, the sideways look, the knowing “are you serious?” rejoinder. It could be Coppola with the corruption and cynicism, it could be Tarantino with the torture and dismemberment, but what it surely isn't, is Billy Wilder.
 
Bred to lie, lying as a default response, lying without conscience, lying in the open, conspiring in the open, defaming in the open, understanding money as the only standard -- Capone would be envious.  Capone would have been better.  He had better taste.  At least he made his money honestly if illegally, and he had no Daddy to bail him out.  Just imagine the training sessions he held for Ivanka, Junior the idiot, and Eric.  They are probably too stupid to learn what "kakiocracy" means.

If it had been Roth who heard what MBS had done, he would have been understanding and understated.  "You know, I told him to be moderate.  We have the world, the whole world to exploit.  There is no credible opposition.  Go slow and steady, and we'll have everything we want.  But no, it was too much to ask.  Young men who have it handed to them have not been tempered.  Their minds break, they lose touch.  Cut the man up?  It's disgusting, and totally unnecessary.

"We'll have to handle it.  Condemn the world of violence, make a show of some sanctions, tell him privately he's have to serve some time in disrepute and we can't be openly supportive.  It'll probably be a year, or maybe two.  Let him know we're upset, but that eventually, if he learns, it won't be fatal.

"Give it to Rocco."

But of course, Roth had worked his way up himself; he had been tempered.  Trump?  Not so much.  And you can't run the United States as a crime family.  At this level, everyone will be going to jail.  I just want to see Ivanka and Jared in orange.  Stephen Miller, the whole cast.  Stylish.

Budd Shenkin

Wednesday, October 10, 2018

The Hazards of Hospital Care


When Hospitals Care Fails Us, Why Should We Not Blame?
Presented at A Writer's Evening, Vanni Bistro Café, Berkeley, CA, 10/9/18



The Case of Ilana Yurkiewicz's Father


Our text for today appears in the July 2018 issue of Health Affairs: 


A young doctor down at Stanford, Ilana Yurkiewicz, recounts the medical misadventures of her 68-year-old father during a two month hospitalization (not at Stanford) following his cardiac arrest. Her dad was very lucky; after a heroic resuscitation with 9 separate shocks over 20 minutes with 6 cracked ribs, he survived. An intern at the time, Ilana and her physician sister naturally responded by taking leave to be by his side kat the hospital.

Like many other doctors who have found themselves in this position, Ilana was shocked not only at being at the periphery rather than the center of medical activity, but also by the multiplicity of errors, instances of careless care, and the obvious deficiencies of organization that the hospital delivered to her father.

I'm going to review the details of this interesting case, review what Ilana thinks it should teach us, and then offer what I think it should teach us, and why we should be very disturbed at the root causes of her father's mistreatment.

Details of the Case – What Went Wrong

As she sat by her Dad's bed, she saw that “Details slipped through the cracks. Preventive measures were overlooked. Complications happened, and then they snowballed.”

On morning rounds “three days after my father's cardiac arrest, his medical team agreed that he should come off the ventilator.” By evening nothing had happened, but “the covering doctor was busy. It would have to wait until the following morning.”

Note: This is a major error in care. Just as justice delayed is justice denied, medical care delayed is often effectiveness denied. And in this case, that's exactly what happened. Because the ET tube stayed in and was irritating, he would have to be sedated overnight. The doctors on the team had written the order to allow the nurse to use her discretion in choosing the dose of the sedative.

This is another error. They assumed the nurse would be competent to make a choice. She wasn't. Ilana and her sister pleaded with the nurse to make the sedation light so that extubation could be effected the next day. But for some unknown reason the nurse elected to give the maximum dose allowed, and as a result their father was zonked out for 5 days. After his cardiac arrest his kidneys were not working well (as every clinician would expect) and it took them a long time to clear the sedative. Total time on ventilator, instead of three days – nine days! Nine days ripe for further misadventures.

Note here what is happening. There is a “medical team.” “Team” may sound like an attractive idea with two heads being better than one and someone always available who knows about the patient, but a team also means a decrease in individual responsibility, extensive needs for scheduling, coordinating, signing off and signing on, figuring out who does what, and in many cases no one really knowing the patient thoroughly. In addition, teams are composed of ICU doctors, in-patient physicians called hospitalists (doctors who work for the hospital for inpatient care), residents (doctors in training), nurses, and other non-physician personnel. Many members of the team are young and inexperienced. There is no one on the team who knows the patient before hospitalization and no one who will know him afterwards. When I hear “team,” I think: bureaucracy, with all the protection from individual responsibility that bureaucracies afford. It was a bureaucracy that missed the extubation because nobody was responsible for it, and it was bureaucracy that scheduled there to be only one on-call doctor at night, who then didn't have time to execute the orders, and it was bureaucracy that over-sedated Ilana's father because the team assigned a less qualified team member who made a bad decision without review in real time.

Back to the text: because the ET tube was in so long, Ilana's father's vocal cords were swollen (I wonder if the tube had been properly placed and maintained) and he needed a NG tube into his stomach for feeding. The resident – a doctor in training, remember – wrote the orders for tube feeding and forgot to say that they should also give him water. The “team” left the arduous task of writing the orders to the junior member and didn't check them over in real time. Because of no water, Ilana's father became thirsty, dehydrated, and delirious – a diagnosis made by Ilana, it seems. Instead of just giving him water to make up for the oversight, the hotshot ICU doc thought the delirium might be because of his kidneys' failure to clear waste products, so he had a catheter placed in his neck for dialysis – very invasive, uncomfortable, with risks – and then after a few days they found that the dialysis made no difference and it was time to pull the line out. BUT, shades of extubation, this time the delay in removal was because … it was the weekend! Can't do anything over the weekend! Because, we don't staff our hospitals fully over the weekend, because everyone knows that patients don't have the same medical needs over weekends. Hey, let's all get some R&R! Maybe the patients should go to the beach, too! Two more days of the catheter.

I'll stop the clinical course there; there were other problems but not so severe, and luckily Ilana's father went home and is even back to work. What a lucky man. And let's face it, even with service deficiencies, modern medicine is great. Modern medicine is great.

Analysis - Hers

Ilona is a smart young doctor, at Stanford via Harvard – smart enough not to stay in the field of general medicine but to have now bolted to the specialty of oncology, where her life will be more controllable – so as she writes this up, she looks for root causes of the problems, as we in medicine are taught that we should do. She assumes that her father’s case is not atypical, because she has seen so much of the same thing in her own experience, as have many others, including me. In fact, many if not most people can recount their similar stories. There is not much literature on the extent of errors (which is an interesting and perhaps indicative fact in and of itself), but we know they are extensive. For instance, perhaps 10% or more of the time doctors miss the diagnosis.

Ilana has been taught to search for root causes and not simply blame the on-call doc for not being available, the nurse for ordering stupidly, the ICU doc for missing the diagnosis, and whoever it is who shuts down the hospital on weekends. But, although she is smart and an excellent writer, she's young and not widely experienced, and not educated about systems and organizations, so her list of lessons is short and not terribly deep. She says that doctors should stop using the passive voice (such and such happened) and instead take responsibility, and appreciate that one error can then cascade, so errors should not simply be excused. Noting that over two dozen doctors participated in her father's care over two months, she says that continuity of care should be honored more, so that the doctors can better appreciate the details of the patient's course. She also notes that technology should be better applied so that, for instance, a warning should appear on the computer when too much sedation is ordered, and feeding water with NG tube placement should automatically appear on the order sheet. She notes that various hospitals are pursuing doing just this (various hospitals – what a national system, where there very few enterprise EHR companies, but where solutions have to be developed separately!)

While they are correct as far as they go, none of these suggestions is exactly earth shaking. Importantly, she does not even mention the presence of or actions by administrative leaders: supervisors, heads of service, administrators, or the agencies that give quality grades to hospitals. She seems simply to accept the existence and structure of clinical teams, and the heavy patient loads that put doctors in the position of having to make the difficult prioritization decisions that screwed her father.

My Analysis

I've been around a lot longer than Ilana, and unlike her, I'm reflexively critical and paranoid rather than complaisant and obedient in the face of large medical institutions. When they teach us not to be angry and complain, but to understand that we are all striving for the same ends, I don't believe them. I think they are trying to shut critics up and preserve their own power, money, and priorities. In other words, I'm realistic.

Are patients and large medical institutions really striving for the same ends? Patients want excellence in care, no question. So do doctors and administrators. But doctors and administrators are the ones in charge, and they want other things as well. Institutions need to teach, so they include residents and students on the clinical teams, which weigh them down and cause delays and errors. At the same time, the use of students and younger professionals save the institutions money by low or absent wages. Large medical institutions are very concerned about profit, not a patient-shared objective. They care about preserving their monopoly or oligopoly status, which actually hurts patients. So, let's not whitewash the potential conflict between the goals of patients and institutions.

Consider the large medical institution as an organization. I like to break down organizations into two types; blame organizations, where the most important goal is to escape blame and not get in trouble, and achievement organizations, where success in achieving progressive objectives is paramount. A sports analogy might be apt. Some sports franchises seek to be as profitable as possible; they keep the payroll low and win as many games as necessary to attract a crowd. By contrast, other franchises have winning as the goal, while not losing money is the constraint. With a large medical institution, one must ask, what is the goal and what is the constraint?

If excellence in care were really their top priority, they would measure it – remember the old managerial adage, you manage what you measure. But their measures of clinical excellence are very general and spotty – e.g, they look at total patient days per diagnosis. Not one thing that happened to Ilana's Dad would appear on a quality report, and the length of his hospitalization would be rationalized by risk assessments.

So what are we to make of the priorities of large medical institutions that measure profitability in exquisite detail, but measure quality of care vaguely? It is important for these institutions to avoid being cited as purveyors of bad care, and to be reputable enough to get enough patients to fill the beds. In other words, as a rule, large medical institutions seek to maximize profitability and view quality of care as their constraint.

So, don't tell me that we are all searching for the same thing, and it's simply a technical issue of how to achieve it.

To go just a little bit further down the chain of command, there are other priorities besides profit and quality. How does a situation arise where there are more patient needs than doctors available, as with night on-call and weekends? It might be a question of personnel cost, but it might also be a question of the convenience of the clinicians. Why did more than two dozen doctors treat Ilana’s father? Ilana says that the case details are missed that way, and she's right. But also importantly – and note she doesn't even mention this – does anyone ever get to know and care about the patient as a person with this merry-go-round of clinicians? Certainly, patients are not involved in scheduling. I’d say the providers schedule with the needs of their own lives the first priority.

So, when institutional officials say don't get angry, we're trying to get to the same place you are, we're trying, I call BS.

Two more points.

The medical industry also exhibits a curious discrepancy: the science of medicine is advancing rapidly, but organizational experimentation and change is slow and rare in medicine. (The invention of the hospitalist is an exception, but it seems that needed reform is now too slow.) Why is that? I mentioned earlier the bureaucratic nature of clinical teams, and the fact that patients are begging for care on the periphery of those teams. Are any serious efforts being made to restructure care so there is caring for and about the individual and not just treating the medical case? Are there any serious efforts to expedite patient demands for care on the wards? Now that primary care doctors who know and care about the patient have been kicked out of hospitals, is there anyone to speak up for them, except for the occasional physician family member, and we've seen how even doctors in the family can be ignored. I haven't heard of organizational experiments to change hospital care, and I doubt that there are many such experiments. Why isn't someone messing around with our inpatient system to get better results?

Knowing and caring about the patient as a person is not only the essence of medicine which being lost in current methods of inpatient care, it's also instrumentally important. It's much harder to put off a procedure or not review orders written by others for a patient you know and care about, as against the arrest in Room 44.

Secondly, not to beat a dead horse, but it bears repeating, a major reason for inaction is that there is no money and no glory in discovering better organizational actions. What's better for patients is not necessarily what's best for the bottom line. My friend, Colleen Kraft, currently the President of the AAP, until last year headed a program at Cincinnati Children's Hospital that successfully kept many patients out of the hospital by enhanced primary care – good for the patients, good for cost. But when the hospital board got wind of the program’s success, they took the only logical step a board could take. They killed the program because it wasn’t serving their prime objective, which was to fill up the hospital beds with paying patients.

Common goals my foot!

I'd like to discuss various ways we could think of to introduce the strengths of primary care onto the hospital wards, but I'm already over my word limit. So, let me leave you with this well thought out conclusion:

IF YOU TELL ME THAT INSTITUTIONS ARE DOING EVERYTHING THEY CAN TO PRODUCE EXCELLENCE OF CARE WITH AS FEW MISTAKES AS POSSIBLE, THAT IT IS JUST TECHNICALLY VERY DIFFICULT TO COORDINATE EVERYTHING, WHILE SOME OF THIS MAY BE TRUE, BASICALLY, IT ISN'T, AND I CALL BS!

Budd Shenkin

Thursday, September 20, 2018

A Letter to the Warriors



Thank you so much for the great job you have done with the Warriors. I have been a fan of the Warriors since about 1949, since I grew up in West Philadelphia and loved basketball early. I had season tickets all during the Don Nelson era, starting in 1988, and in the last decade have attended regularly.

I have seen the game evolve in many ways, most good. But one thing I have noticed is not about the game itself, but rather the way the country has evolved in its idea of patriotism. I am as patriotic as the next guy, but patriotism means many things. Specifically, when the flag is rolled out at the beginning of the game, I find it disconcerting that it is almost always in a military context. While support for military troops is important, it is also important to show support and gratitude for those who serve us in other ways.

I would propose that you consider this: when the flag is rolled out, could you have “honor guards” consisting of others rather than simply military people? What about teachers being out there with the flag, and the crowd asked to show support from them, who give so much? What about first responders? What about pediatricians, for that matter? Hell, I wouldn't object to VC's! Everyone contributes to America, and we should be willing to share the gratitude widely.

Again, thanks so much for your own very worthy contributions to the game of basketball and the people of the Bay Area. I would hope that you would see this suggestion as consistent with who the Warriors are, and what the NBA is, as contrasted to other, perhaps less mindful sports.



Sincerely yours,


Budd N. Shenkin, MD

Wednesday, September 19, 2018

Stuart and Brian


https://www.thecinemaholic.com/wp-content/uploads/2016/05/spielberg-scorsese-depalma-lucas-and-coppola.jpg

There it was on my Twitter feed – what a word, “feed”!, like when little Lola looks at her grandfather and with exquisite economy of words, opens her mouth and points her finger down the gorge and says, “feed!” – a picture from 1994, of Spielberg, Scorsese, Coppola, Lucas, and Brian DePalma, all of whom had ascended to movie immortality in the 70's, drinking after dinner at Lucas's 50th, big smiles, white tablecloth, hair still dark although some beards white, the immortals. What would they do next? We know, because it's now the 20-teens, and the future has been written, and we know that they never really descended, they just moved on and in Spielberg's case even further up, and it's still hard to say they weren't the best.

But what I know and others don't, probably, even Brian himself, is what happened before, and where another fork in the road ended up. Because I am just one year younger than he is and for four years we went to the same school, Friends Central School, just outside of Philadelphia, a Quaker school that still had some Quakers but they were a minority in their own school. We were Jews, of course, (not Brian, but the rest of us) from West Philadelphia, I was on 47th just off of Osage, Bob was at 46th between Osage and Pine, and Stuart was on Osage between 46th and 47th. Our parents knew each other, so we knew each other, and somehow all three families, and Billy Loesher's family from 46th and Osage, too, all had found FCS and had abandoned the inadequate local Henry C. Lea Elementary School.

We commuted together in a dark green station wagon supplied by the school, with a driver who came by and picked us up at our houses and took us the 45 minutes or so over city streets, out Walnut to 63rd and then North past J. McCullough, Undertaker and various other landmarks that we imbibed daily as we drank in the parts of the city we would never see otherwise – well, maybe Bob would, but I wouldn't – and it was Bob (then called Robert), the four of us Shenkin's, and Stuart Egnal. And a few others. I must be misremembering, because how could such a crew fit into that dark green station wagon, I wonder?

Stuart was a year ahead of me, and I was a year ahead of Bob. Stuart was bigger than I was by a little, his father and mother being a little bit bigger than my parents. Mike Egnal was tall and lanky, a lawyer, and in the summer he ruled a public tennis court down in Beach Haven, NJ, saying who would play when. My father envied his dominance somewhat, I think, as he did the social savoir faire of lawyers who, when a situation arose, somehow knew how to take charge, while my father's dominance was confined to the hospital, where his prestige as a neurosurgeon conferred the rights that Mike seemed just to assume on the tennis court. Mike's wife, Stuart's mother Sylvia, had a similar physique to Mike's, above average height, wide shoulders, and more respectful and non-intrusive than most of the Jewish women I knew and would come to know. I came to understand that she had eyes on me for her daughter Betty Ellen, a couple of years older than me and later on at Radcliffe when I got to Harvard, but I didn't see her there, although I think Sylvia wanted me to look her up and Betty was receptive (maybe obediently) but she had her own life and I think she wound up in London, like my youngest sister, Emily, and I think she was in art history. I'm not completely sure she was in art history, but I think she was, but I'm positive she wound up in London. Come to think of it, I think Sylvia painted.

When you finished 6th grade at FCS you moved across the roundabout at the end of the driveway to the Upper School, which was to my eyes a Victorian sort of building, with towers, wood floors, and narrow or medium sized hallways, and classrooms with warm lights and windows that looked out on trees and greenery that you wouldn't see around West Philadelphia. Sunlight and green trees and grass and bushes and little swales filled me up with something, a feeling of being saved, a feeling of luck, a feeling of being taken care of by my parents, a feeling of luck, and a feeling of being somehow out of their element and therefore a little out of mine, too, but accepted by these Quaker step-parents who were patient with me, even with my high-spirits, and some even liked me, like Mr. Burgess. Everyone had to play sports, and even if my parents weren't as big as his, and even if I was a little smaller than he was, I still thought, I knew, that I was a better athlete than Stuart. He was OK, but I was better. And even if Betty Jane was smart, which I didn't know at the time, I knew that Stuart wasn't that smart. How do these genes sort themselves out, I wonder? It's a puzzle, even if we know 99.9% of our genes are identical, that .1% is pretty powerful, and I don't think it's just environment. Or maybe it's just the differences we concentrate on. I don't know.

Stuart hung around with Brian; they were in 8th grade when I was in 7th in the Upper School, just getting used to the Victorian architecture instead of the less elevated functional architecture of the Lower School, where Miss Reagan would still take a half-hour now and then to read a book to us all in class – can you get that, reading a book collectively to 6th graders? I'm sure that doesn't happen anymore – and I remember she read to us about Chaim Solomon, who was depicted as the brains behind the financier Robert Morris, who funded the American Revolution. Was there a reason they picked that book, were they nipping at anti-Semitism in a school populated by a significant number of suburban gentiles who chose private school over the quite acceptable suburban public schools, the gentrified business people of the Main Line? Or in the case of Brian De Palma, the son of business but of a physician my father knew, whom my father thought he outranked even though he was Jewish, because after all my Dad was a neurosurgeon, and one who had excelled as a resident at Penn, indeed, had been legendary (if abrasive). Tony De Palma was an orthopedist at Jefferson, and when Brian's name came up, my Dad recalled that yes, he knew his father. Doctors tended all to know one another in those days, I think, there were so many fewer, and orthopods and neurosurgeons were sometimes rivals.

As I carefully roamed the narrow hallways and back stairs with windows to the natural world of the Upper School, since I was in 7th grade and then 8th grade – my last year at FCS, since we moved to Lower Merion over the summer and I switched to Ardmore Junior High and then Lower Merion High – I was conscious of myself the way an early teen is, for the first time, although I didn't notice that I had grown a new part of my brain that seemed to observe me. Those are the years of your life that you turn into different streets of life, not necessarily mean streets, especially in the suburbs, when girls stop being just an annoyance, when you can do the harder math pretty easily, when your shots start falling into the basket more readily. These are the years that a parent wants you to be around good influences, caring people, and nice kids, to be able to see trees and bushes and the sky around you and to smell the spring and trample on the turf. Those are the years when you find out more about what you're good at and what you like, and where you continue to find out where you stack up.

I was lucky. I was good at things. I was good at math and science and reasoning and I read on my own, although I don't think I was much of a writer. And I was the best basketball player in my grade and I played shortstop and I hit well, and I even was good at football where I ran the ball and intercepted well on defense and could field a punt surely. Stuart was a year ahead, with Brian, and even though his father was a lawyer and his mother intelligent and his sister would be going to Radcliffe, Stuart just wasn't that smart. I guess we were rivals, but I'm competitive, so I guess we competed, at least in my mind, I guess predominantly in my mind, reflecting my father's mind which always seemed to have a tennis ranking system in place, with intelligence as traditionally conceived the means of ranking, and with intelligence mediated by grades. I got good grades for achievement and lesser grades for behavior. I imagine the parents talked about their kids' grades and struggles and achievements, and compared and competed and worried (what anguish that could be), and hoped. Hoped the way Coppola's Brando wanted Michael to pass into the ranks of the pezzonovante, a Senator or Governor or something like Kennedy, I would think. Years later, when I decided to be a pediatrician and not a hotshot academic or something in government, my mother observed that I had chosen “a little life.” My Mom had a way with the cutting bon mot, concise, hurtful, she thought realistic. I don't think Sylvia indulged in that, but who knows outside the family?

My Mom sat me down one day and told me I was smart enough that I could be anything I wanted, except maybe a mechanic or someone who put things together. I objected that I could be a mechanic if I wanted, and her desired positive insight and support turned into a stalemate. I guess she wanted me to put an eye on the prize as I wandered, and it was true, I wasn't good at choosing, never was, and not helped by her who kept choosing for me, maybe trying to help, but maybe just impatient with me, when she chose rapidly and decisively and I could hardly figure out later on which brand of shaving cream to settle on down at Ricklin's Hardware in Narberth. They say that sometimes in a family temperaments are mismatched, and that's what I've settled on for my diagnosis.

I wonder what Sylvia would say to Stuart. His default would be to be a lawyer like Mike, and like his younger brother Johnny would be, but Stuart wouldn't have been up to it. He was spirited, though. I remember walking through the Upper School hallway and coming upon Stuart and Brian, just outside the door to one of the classrooms and beside an exit to the second floor stairs, with driveway below and trees and sloping field out the back, towards where now the Lankenau Hospital has filled in the entire landscape, which we saw arising just at that time with orange girders looming above the football field, and there they were, the two of them, spirited. They had bent down in half deep knee bends so their thighs stuck out in front of them, and in unison they were clapping their hands together then hitting their thighs and doing a drumming beat and they were chanting, I remember so clearly, something I had never heard before, “It's a treat to beat your meat on the Mississippi mud, it's a treat to beat your meat on the Mississippi mud,” with naughty smiles as their classmates walked out of the room and onto another class. Their voices had changed and the chant was low-pitched. This is my memory of them, two friends with a common spirit.

The last time I saw Stuart was outside the American Express office in Paris, as we picked up mail in the summer of 1962 on vacation, just running into each other. I was with my brother, about to pick up a blue Volkswagen bug and drive it down to Greece and back to Amsterdam and send it home so Bobby could drive it to the University of Michigan where he would be a sophomore. Stuart was there with other friends, and he told us with excitement and expectation and a little bit of wonder that he was there and doing that, that they were going to Spain. Spain was ruled by Franco, and cautious as I was, inherited from my parents' McCarthy days experience, I wouldn't for a minute think of going there. We took off for Italy instead, untutored in the world, driving a lot, and getting homesick maybe, meeting some girls, not knowing how to have too good a time, maybe, I'm not sure. But Stuart was headed to Spain.

And Stuart had decided to be an artist. An artist? Who decided to be an artist? Who knew he could draw? Could he draw, or paint? Who knew? Who did that? Who didn't become a doctor or a lawyer? The way Russians and Indians become engineers. Stuart an artist? But yeah, Sylvia painted, I'm sure she did.

I actually still have a painting that Stuart did, I think, maybe somewhere, or maybe just in my mind. It was a pottery vase, yellow, with a plain medium blue background, maybe it was OK, or good, or who knows, it wasn't Picasso, but it sure wasn't something that I could have done, either. A 36 inch tall picture, maybe. But after that meeting at the Paris American Express, the next time I saw the Egnal family was a few years later, when they were supposed to be sitting shiva after Stuart died of thyroid cancer. He must have been in his twenties, and my parents pushed me in through the front door of their house without knocking, because as far as they knew that's what the tradition was, and because my mother said “Stuart was Buddy's friend,” and because I always seemed to be pushed forward, and we saw the Egnal family à table, just the four of them then, and they looked up surprisedly and didn't know what to make of the intrusion at first, and then Sylvia looked up from her end of the table that was facing me, and said, “Buddy!” and came over and was emotional and welcoming and I wondered if I had been closer to them and to Stuart than I knew. Johnny had visited Stuart everyday he was in the hospital, out at Temple I think I remember, and been a good brother to the end, somewhat to my wonder because I just remembered him as a kind of clutzy younger brother. What does one say when a child dies, even if he had struggled there were still hopes and love and what do you do? You just lean on yourself and others and even if you're not religious you lean a bit on God, I think, and hope there's something in the world or beyond it, something somewhere.

But there was Brian, so much like Stuart in my memory, with Marty and George and Francis and Stephen – but no Stuart, and of course even absent the cancer, there would have been no Stuart in that picture, of course. It's only in my mind.

The last time I saw Sylvia was at someone's funeral, maybe my Dad's, I don't know. She was still living at their house on Osage, by herself, Mike having died many years ago after years of debility, and she seemed a little smaller but still somewhat rangy, still driving herself, at the age of 96. Amazed at herself. I wonder if she liked Brian's pictures? I wonder if she saw them.

Budd Shenkin

Thursday, August 23, 2018

The Climax Approaches

Yes, the commentators can't resist saying that Manafort's conviction - one vote short of guilty on all counts - and Cohen's plea and accusation do not mark the end, nor the beginning of the end, but perhaps the end of the beginning.  They lose no chance to repeat someone else's bon mot.  They reflect on how long Watergate took to come apart, or to come together, whichever way you look at it. 

But I'll stick with my analysis of last month when I said, comparing Trump to a stock, that the tax bill was probably the high, and the lows now lie ahead.  I'd say that yes, Watergate took a few years, but then Nixon was smarter than Trump by a lot, and the path to impeachment was not well known then.  Watergate has lit the way, though, and now we can see our way forward more clearly.  We'll go faster this time.

So I'd say the end has begun and things will travel a lot faster than people think.   Why are the GOP leaders so quiet?  Don't they see the end so clearly?  Don't they understand how silly they look?  What I'd say is this: I think they see it very clearly indeed; they just want to get in their last licks.  The GOP objectives have been destroy ACA (in process), get a big tax bill for the rich (done), and fill SCOTUS with young conservatives (one down, one to go). 

So,that's their motivation for silence and Trump-toleration at this point.  As soon as Kavanaugh is decided, one way or the other, they won't have much more on their agenda, and they will be able to go back to electoral politics.  At that point the dam will break, and as they open up Donald will find himself without a life raft.  What will they care?

The Kavanaugh affair is then the final act of the Trump Crime Family Administration.  But, even though we might picture that as a relief, it really won't be.  It's hard to predict what will happen, but the bitter fight will go on, the GOP will continue to be enemy rather than opponent, they will fatuously claim that this is the time for "unity rather than divisiveness," and the Dems will be tempted to hear that siren song; while some will say we need justice, others will say that will be too divisive, etc. etc.

As for me, I will count myself as being among those who will take pleasure in every orange jump suit and ask for more, until they get Ivanka and Jared along with the easy mark, Donny Junior, and the other merry band of miscreants, the stupid evils of the Trump Crime Family Administration.  Personally, I'd like to see justice meted out à la Nuremberg, and I'd like to see the evil-doers in the dock à la Goering and Joey Goebbels.  But that's unlikely, and I guess I'll have to be satisfied with the jump suits.

What crooks they are, with every fiber and down to every pore!  Crooked beyond crooked!  Carpe diem, be here now, watch them get locked up.  I'm just waiting for Act V.

Budd Shenkin