Saturday, May 23, 2015

Thrifty Scots


The Royal Bank of Scotland is one of the six miscreant banks to plead guilty to currency manipulation. Here on the ground in my first visit to Scotland, it's hard to imagine the evil that such men do (I would suppose they are mainly men.) Our visit has revealed a wonderful, warm people, who generally cannot help us enough. I do see where the moniker “thrifty Scots” comes from: every piece of information and direction we get has not only a cost attached but an opinion of whether it is exorbitant or not(“his tour is very good and not as expensive as Jim's.”) Probably because I'm an East Coast Jew, it sounds reasonable and refreshing to me.

At a woolen store today in Edinburgh I scandalized my WASPy wife Ann by buying sweaters and a blanket and asking, “What is my discount on this?” She scowled and walked away. The Japanese salesman asked his young Russian emigre manager Denis about it, and Denis apologized that he could only give me 5% off, but explained that the VAT rebate at the airport would deliver me 10% more. Denis

I asked Denis about he emigration and asked if he was Jewish, and he said no. He did have a Jewish friend back in Russia, he said, who never paid for anything, and then when he did pay one time, all his friends applauded.

“Why did you do that?” the friend asked.

They answered, “Because you never pay for anything.”

Reflecting on his story, then Denis asked me, “Are you Jewish?”

I said that I was. He said, “No offense.”

None taken. After all, we were in Scotland, and he had just given me 5% off.

But I digress. Who would have thought that the RBS was filled with crooks, because the people seem so nice? On the other hand, listen to what happened to us yesterday as we made our way by ScotRail, the national railroad of Scotland, down to Edinburgh, a pleasant trip of about four hours.

First, on the day before, I bought the tickets on line. Because it was a lengthy trip we bought first class seats. Instead of the regular fare of £83.80, first class was £131.40, about £48 more. We reserved seats, showed up on time, got on the train, and found out to our astonishment that we were seated in the regular coach, not first class. We inquired and found that others were in the same situation. ScotRail had figured on two first class cars but then decided on only one. OK, not a tragedy, but we would be due our first class fare back, of course. The conductor marked our tickets with some scribbling and told us that when we got to the station in Edinburgh we could go to the ticket counter and get our money refunded. Fair enough.

Except, not fair enough. We found the ScotRail ticket counter after a couple of tries and the curt clerk at the counter told me that since we had bought our tickets on line, we could only get a refund on line. Bizarro! How do you get a refund on line? How do you show them the tickets with the conductor's scrawl?

But, having no choice, when we got to our hotel, spirits buoyed by a terrific room upgrade, I set to work at the ScotRail website, division of customer support. I explained my problem:

Sirs:
On 21 May my wife Ann and I purchased by internet first class tickets to travel from Inverness to Edinburgh on 22 May on the 10:45 train.  Our ticket numbers are 02308 and 02309.  Our seat ticket numbers are 02310 and 02311.  When we arrived at the train they told us that a first class car had been cancelled and we needed to take ordinary seats, which we did.  They told us that the extra premium we paid for first class would be refunded at the Edinburgh station.

Unfortunately, when we sought payment at the station we were told that since we had purchased the tickets on the internet, we would have to seek restitution over the internet, hence this communication.

We would very much appreciate our first class fares being refunded.

I can be contacted by email at buddshenkin@gmail.com.  My cell phone number from the US is 510-918-0698.

Thank you very much in advance.

Budd N. Shenkin, MD

The return email said:

Case Logged Notification. Reference: SR/150522/CDQJ

Thank you for contacting ScotRail.
We aim to reply to emails within 7 days.  If however, you need a quicker reply please call us on 0344 811 0141.  Alternatively you can visit our website scotrail.co.uk for live train information, to plan a journey, buy tickets or visit our Frequently Asked Questions.
Kind regards
The ScotRail team

Seven days seemed a bit long, especially since we would be long gone by then, so I availed myself of the telephone number and explained our problem to the nice young lady – young – who took it in and said that she would have to get me in contact with Marie, who handled such issues, would I mind? No, I didn't mind, and young Marie – young – took in the situation, and explained that ScotRail did not issue actual money back, but vouchers which could then be used to purchase ScotRail tickets, or could be turned in for cash. Would I please mail in the tickets?

“Mail?” I queried. “Mail?”

“Well, I guess you could take a picture of them and email them to me.”

OK, that sounded possible. What would happen then?

“Then we will mail out your voucher to you within seven business days.”

“But we are only here in Scotland two more days, and we will be flying home from London in 10 days.” There is, of course, no place in London to cash in vouchers. And since this was a Friday and a three day weekend facing us, it would be unlikely that a railroad company would be working for some time – especially since the railroad union was threatening strike on Monday and Tuesday, for maximum disruption (wanting higher pay since they make only about 40% more than police or firefighters – shades of BART in the Bay Area! But I digress again.)

“I'll talk to my manager.”

OK, she was a sweet young thing, trying. She came back on the phone and urged me to send them to the same address where I had sent the first note and to attach a new case reference number she gave me, even though I had been assigned one

“If you can get me the tickets by 2 PM on Saturday, we can try to mail out the vouchers on Monday. Where can we send them to?”

Good question, good question. Where, indeed?

I complied nonetheless with the following note with the title of the new case reference number she gave me:

SR/150522/CDRG


Budd Shenkin




to customer.relat.

Sirs:
As I explained in a phone call and in an email, on 21 May my wife Ann and I purchased by internet first class tickets to travel from Inverness to Edinburgh on 22 May on the 10:45 train.  Our ticket numbers are 02308 and 02309.  Our seat ticket numbers are 02310 and 02311.  When we arrived at the train they told us that a first class car had been cancelled and we needed to take ordinary seats, which we did.  They told us that the extra premium we paid for first class would be refunded at the Edinburgh station.

Unfortunately, when we sought payment at the station we were told that since we had purchased the tickets on the internet, we would have to seek restitution over the internet.

We would very much appreciate our first class fares being refunded.

When I spoke to your representative, Marie, who was very nice, she explained to me that it was policy that the only refund would be by voucher, which could be redeemed at a ScotRail office.  (Why ScotRail cannot credit the sum to the same credit card to which the original fare was charged, remains a mystery.  That is certainly what other enterprises are able to do.)  She also explained that it would take some time for such a voucher to be issued.  It is unfortunate that we are at the end of our Scotland visit, and expect to leave on Monday May 25 for England.
The representative asked for copies of our tickets.  See attached.  She also asked for where the vouchers could be sent.  We are staying at the Waldorf Astoria Caledonian Hotel in Edinburgh until Monday.  If the vouchers are to arrive after that time, they should be sent to my sister's house:
Emily Simon
9 Elsworthy Road
London NW3 3DS
United Kingdom

I can be contacted by email at buddshenkin@gmail.com.  My cell phone number from the US is 510-918-0698.

Thank you very much.

I then received the following reply:

Case Logged Notification. Reference: SR/150522/CFCT


Customer Relations





to me

Thank you for contacting ScotRail.
We aim to reply to emails within 7 days.  If however, you need a quicker reply please call us on 0344 811 0141.  Alternatively you can visit our website scotrail.co.uk for live train information, to plan a journey, buy tickets or visit our Frequently Asked Questions.
Kind regards
The ScotRail team


SO, we now have at least three different case numbers and a promise for them to hurry up to issue us vouchers for which we will have scant ability to exchange for the cash they already took from us. In essence, as Ann summarizes it, they took our money in exchange for a seat they promised but could not produce, and now refuse to refund our money.

The irony is that this occurs in a country that is so punctilious about financial matters, so watchful, so financially conscious. As always, one asks, is it stupid or evil? Or as in most cases, a bit of both? For RBS, evil wins the day. For ScotRail, I figure it's both -- stupid in bureaucracy, but evil in screwing the public. 

I'm just trying to figure if my 5% discount from Denis covers my £48 loss to ScotRail.

Budd Shenkin

Tuesday, May 19, 2015

More Advice For Hillary


A month or two ago I posted a memo to the Hillary team to the effect that she go after issues, and fill all campaign space with them immediately. Doing so would show the results of her experience and knowledge, which would be better than just claiming those qualities. Doing so would also deflect attention from the usual person-based commentaries which generally do her no good. Also, in the event that she wins the presidency, having a record on the issues would enable her to claim a mandate for pursuing those issues.

Now I have a follow up proposal. She should base her issues on one common theme: infrastructure. She should say that it is not the government's role to achieve success directly, but it is the government's role to enable as many as possible of its citizens, and its businesses, to do so. It is government's job to get them up to the stage; performing is then their responsibility.

Infrastructure conventionally means buildings and roads, I guess, and that's a good place to start. It's traditional. Lincoln's Whig platform for election was for the government to promote the expansion of railroads. Eisenhower famously promoted the interstate highway system. Both Abe and Ike came from areas that benefitted from the programs, rural Illinois and rural Kansas. Both knew what it was like to be isolated in a backwater. Hillary can't claim their personal experience, but pressing for increasing road and bridge maintenance is something everyone knows we need. Governments can be so foolish in overseeing decline. It was so disappointing for Ann and me last year to visit Spain and ride our busses on roads of a quality simply unobtainable here at home. We just have to make sure that California's personal nemesis, Caltrans, is not allowed anywhere near any of the projects.

Infrastructure needs to expand its definition beyond roads and buildings. Band width and speed are commonly granted admission to the “infrastructure” rubric. Again, how can we be 28th or whatever it is we are in the world in computer technology infrastructure? Scandalous.

I would also include health and education in the “infrastructure” definition. After all, aren't they human infrastructure? In both cases, direct government provision is not necessary and not desirable. Government influence and regulation are necessary; government financing is desirable; but government completion of the duty is not desirable. Both inefficient fields are undergoing reform; Hillary could simply pledge to improve Obamacare, and to expend more money and effort on the schools supporting current reforms of all sorts, including improving Obama's Community College is Free program.

OK, it's not an imaginative list of responsibilities for government, but that's OK. None of these are new areas, and none of them new for government, but that's a good thing for an election. Who needs a new program on the docket? What she needs is a declaration of what she would devote her domestic efforts toward, a set of issues that are non-controversial as governmental concerns, and a set of plans for how to get there, which can be craftily assembled.

Let the Republicans carp about the details; if they play on her turf, she will likely win. What she would hope for would be Republicans to contradict her goals on the basis that it would entail raising taxes. Indeed, some taxes might need to be raised, or maybe not. But the answer to them would be, “You're willing to let our infrastructure decay, for our capacity to grow to decay, for us to fall behind, so taxes can be low? Really?”

And then she should add that the problem with taxes is not really how high they are, especially for the wealthy, but whether or not one is getting a good deal from paying them. Is the government doing a good job with the taxes? The first requirement for doing a good job with tax money is aiming at the right goals. Are the Republicans saying that infrastructure is not the right goal? Make that case, guys! Or, if it is a worthwhile goal, how else would you achieve it, non-governmentally? Answer me that.

And she could add one thing further. She, too, is concerned about the effectiveness of government. There have been studies and studies about how to make it more effective, how to “reinvent” it, and some efforts with some limited success. Well, she could say, I do think we need constantly to work at making government more effective. So I would establish a government effectiveness commission to constantly chip away at this issue, to call for whatever civil service reforms need to be made, whatever changes in procurement, whatever changes in scale and organizational location. I would get the momentum going, and I would appoint lots of Republicans (including Tom Coburn), and lots of rather non-partisan knowledgeable people on this commission, and I promise I would listen to them. We would get government to work better. Big or small, government will always be with us. It doesn't make sense to give up on it and say it will always be so. We can learn from academics, we can learn from our own excellent officials, we can learn from the experience of other countries such as Singapore, and Scandinavia. Not everything, but something. Not complete victory, but making good progress. And I would be sure that by the end of my tenure we would be better off.

OK, maybe not visionary, maybe not inspirational, but Hillary is neither one and never will be. But it is workmanlike, doable, stable, forward-looking, progressive, inclusive, and defensible. It would be pretty hard for the Republicans to be critical, I think, hard to call it anti-business, hard to call it big-government, hard to call it soak-the-rich. Democrats would want more, and they could get more, but if she concentrated on infrastructure, she could get pretty far. She needs the image of down to earth and practical. Let the Republicans wax theoretical, let them say one after the other at a debate line up that they disagree with her priorities. What could be sweeter.

So, that's my suggestion. Let's see if the Campaign likes this one as much as they did the first one.

Budd Shenkin

Wednesday, April 22, 2015

Sarah Chayes Responds

Budd, thanks so much!  I really appreciate the thoughtful read, and the time you took to write both.

Best regards,

Sarah

Sarah Chayes
Senior Associate, Democracy and Rule of Law Program & South Asia Program
Carnegie Endowment for International Peace
1779 Massachusetts Ave, NW | Washington, DC 20036

Sarah Chayes



Tuesday, April 21, 2015

One Word, Two Ideologies


When I was a boy I imbibed my politics from my parents. I was the first born and my mother was only 23 when I was born, which was usual in those days, so I got the politics dose when they were still young, in their 20's and 30's. They had been lefties, not Party members I think, too independent for that, but close. So I learned from my mother directly – walking on 52nd street to the shoe store and finding a little picket line, she told me “Never cross a picket line.” Sounds like my sister Kathy, actually, as I say it now to myself – these things get transmitted. Also walking on 52nd street, I heard from her: “From each according to his abilities, to each according to his needs.” (It's still hard to navigate the language here, isn't it? “His or her” is cumbersome, and “their” is ungrammatical. What to do? I think “their” will become grammatical. But I digress.) I also heard from my mother, “The land was desert under the Arabs; when the Jews came they made the desert bloom.” Ah, it seemed so easy.

As I got older it got more specific. I heard “Mossadegh” and “Arbenz” and the “Dulles brothers” and “McCarthy” and “United Fruit” and took it all to heart. Didn't hear anything about the CIA because it was too young to be notorious, I guess.

I think when my father said something, he had an air of thinking about it and weighing things, whereas my mother tended more to have shorter answers expressed as received wisdom as a guide to politics. I tended more toward my father's views, taking things only under advisement. My mother looked to him as the senior opinion, I think. She said of him, “He has this big brain.”

When we all got older and moved to Wynnewood on the Main Line in the 50's, when my parents got to their late 30's and 40's, their views moderated. I remember my father looking at the paper at dinner and saying, “That Texas Utilities stock just keeps going up!” His stake in society was changing. And one day an visiting English physician came to dinner and my Dad said, “What are your politics?” The guest said, “Well, I think both sides go a little too far,” or something like that. And my father preempted any further discussion by saying, “That's what I think, too.” I looked down at my plate, noting the change.

I explored more in college, noting the views of leftist friends, still holding my tending-Left positions in abeyance. I audited a course by Robert Paul Wolff, an avowed Marxist with a terrible facial tic, telling my friend Fred, “I really want to find out what my father was thinking.” I didn't take Kissinger's course on Nuclear Weapons and Foreign Policy, which I now regret. I had to make hard choices on which courses to take, so I rationalized some of the choices, in this case thinking that there was something sinister about Kissinger. Instead, I took David Reisman's course on something about American society, liberal.

Now I'm a lot older, but I'm still trying to sort it all out, tell you the truth. I read and think. I like Kissinger's books; I like The Clash of Civilizations and the Remaking of World Order by Sam Huntington. I note the ravages of aggressive American foreign policy and the ravages of the oil companies – worse that United Fruit – but at the same time I remember how wrong people were about the Soviet Union, and the real need to protect freedom, which is not just a myth.

“Freedom” is a very general word. I have thought for a long time now that to conservatives“freedom” means the free ability to ply the capitalist trade anywhere, as United Fruit and the oil companies did and do. To liberals “freedom” means democracy and human rights and good government; for some reason I think of Jimmy Carter as an exemplar. One word, two ideologies. Governmental agencies – CIA-State Department-DOD – waver between the two, but mostly incline toward capitalism as our national interest, probably.

Which brings us to this new book, a terrific and short one, by Sarah Chayes, the daughter of a renowned Harvard Law professor, my friend Michael reminds me – I thought that name seemed familiar. Her book is “Thieves of State.” It is short at 235 pages, which is a blessing, as it can then be concise and convincing without a lot of adumbrative claptrap. http://www.amazon.com/Thieves-State-Corruption-Threatens-Security/dp/0393239462/ref=sr_1_1?s=books&ie=UTF8&qid=1429548795&sr=1-1&keywords=thieves+of+state

Chayes' thesis is that failed states are not really failed states, they are countries captured and run by criminal associations. Their modus operandi is the shakedown at all levels. Therefore, the strategy of the United States – first to establish stability and only afterwards to root out corruption – does not and cannot work. Oppression is not a good strategy for the long term.

Chayes starts with Afghanistan, where she started out working for NPR and then left to work for an NGO headed by the older brother of one Hamid Karzai. She soon discovered that the Karzai's could easily have been directed by Francis Ford Coppola, the only problem being to decide who was Michael, who was Sonny, and who was Fredo. She literally watched the CIA hand over large bills to one of the brothers wrapped in aluminum foil. She did not witness the obtaining of a receipt.

The story in Afghanistan is not unexpected by anyone who has read even the basic books about the Bush Wars of Adventure that have left us in a generation-long hole to crawl out of. The incompetence of the US leadership is also not unexpected. The scale of both, however, is bowling-over unexpected. Just unnervingly corrupt, just unnervingly incompetent. It's enough to make one say, “Enough already! We're outa here,” no matter how convincing Kissinger (“World Order”) and Brent Stephens (“America in Retreat: The New Isolationism and the Coming Global Disorder”) may be on the need to remain involved because the world does need order. In the end I actually can't say we should be outa there, I think we need to help maintain order, but boy, we sure shouldn't do it this way.

Chayes' thesis to end corruption first is based on obtaining the good will of the people. They are the ones who are actually oppressed and extorted. Chayes cites four or five “mirror” would-be ruler advisers, the most familiar being Machiavelli, who have sought to bring reason to rulers through the ages. They all say the same thing, that you have to be basically fair to the people, responsible for them in rooting out the corruption of your subordinates, etc. If you don't act this way, they will revolt, and that the revolt will often be based on an extreme religious element, such as Martin Luther. Viewed this way, one comes to think of the Taliban and other Islamic movements as a typical reaction to official corruption.

So, if the ordinary citizens see the US in cahoots with their oppressors, how can order be established? All the wisdom is there for the reading, if anyone involved in these fiascos can read and reason, which is not a given. Instead, the military will opt for military means because it is hard to redirect them, for all the flexibility of intelligent leaders such as generals McKiernan and Petraeus, and Admiral Mike Mullen. (Chayes actually served on the staffs of McKiernan and Mullen.) The CIA will opt for cynical insolent secret deals with the cynical, sinister leaders and think themselves coldly realistic as they hand over the cash and don't tell the other parts of the US government what they are doing. The State Department will be its usual pusillanimous self. Eventually, getting outa there is often not voluntary.

Some little sidelights Chayes mentions made me think of another view of these terrible events and trends. Mubarek's son Gamal came back from his education in business in London and figured out how to corner more and more wealth in Egypt in new and modern ways. The gang in Russia was also clever in privatization. I think the top families in Angola and in Tunisia were also enlightened by Western business ideals. (Chayes points to the importance of families in kleptocratic enterprises, resisting somehow citing Sonny, Fredo, and Michael – I wouldn't have been able to restrain myself.) Is this why Boko Haram means “Western Education Is Forbidden?” B-schools teach no morality, just what works is good. The US sees no limits to inequality. There is only lip service to serving the general populace, making up the rationalization of trickle-down, saying that what you want to do is what ought to be done. Morality matters, and Western morality as conveyed by B-schools is a problem. It's capitalism as “freedom,” rather than civil rights and good government and free speech as “freedom.”

How does this happen? Hegel believed that ideals led to economic and political consequences. Marx famously turned Hegel on his head and asserted that economic relations to the means of production was the primary force in determining economic and political events. My stance (which the world is doubtless waiting for) is this: whatever. They're related, as the egg is to the chicken. When they form a self-reinforcing system, ideas and reality, the situation gets pretty ingrained. Where crime can happen, crime will happen.

So, here we are. It's nice to think of a Westphalian world where states respect each others' boundaries and internal politics, where legitimacy is respected inside and outside of the state. Unfortunately, with these kleptocratic states, that's not going to be possible. They will experience upheaval and threaten those around them and increasingly the rest of the globalized world. It's not a bad idea to try to help the states develop internal legitimacy and coherence. But to help them, the helpers need to understand both those states and the mirror-writers and history. There is little evidence that this is happening at anything like the scale we need.

It's a powerful argument in a short book. I think my father would have liked it, and my mother would have agreed. What will work is good government, and the ideology of freedom of speech, freedom of worship, freedom from want, and freedom from fear – all based on people and their needs and a legitimate government – not the freedom of rapaciousness the capitalists have brought us. Cynical realism is unrealistic.

Budd Shenkin

Monday, April 20, 2015

Hillary's Campaign


It's all so silly, really. At least I think so. It just seems pretty clear to me, especially since I have absolutely no inside information, no scientific information, no polls, nothing. But I do pay attention. We're talking about the campaign.

Number one: is it a problem for Hillary that she is essentially unopposed so far? It's an unfamiliar situation to the pols and pundits, so they say she needs opposition to sharpen her game. Well, no, I don't think so. If she's not sharp by this time after all her political life and campaigning, she's not going to be. One or two warmups and she should be sinking three-pointers if she ever could.

Second, though, think about this. What do you do when you are running in the primary? You have to calculate your angles so you get the nomination, please this faction and that faction who are the activist voters in the primary. Then you have to reset your positions for the general election, as Mitt Romney's campaign manager so usefully told us in 2012. Well, she won't have to do that particular pirouette. She can hone her positions from the start to please her “base” enough to excite, and to go to the general without having to disavow anything she said, and in so doing appear “political,” untrustworthy and unprincipled, which is a common suspicion with Hillary. She avoids pot holes.

Third: her problems are likability and her inability to fire up a crowd, to inspire, to come across well in public. Fine. Those are her problems. A professor at the Goldman School of Public Policy at Cal told me in 2007 or so that she would never be President because she's a Methodist, and I think this set of problems is what he meant. She might down shots at a bowling alley in central Pennsylvania, but is she someone you would like to have a beer with? I dunno, maybe. I don't think Methodists drink much. But I think if she is to be likable, doing a primary race isn't going to help with that. There's a better opportunity to be likable when some of the pressure is off, when you are running a campaign without an opponent who you have to jab, when you can appear and make your case while the other side is in flux.

Clearly, likability isn't her strength. And as Dahlia Lithwick said, people are already tired of her and she hasn't done anything yet. So what should she do?

I think she needs to capitalize on what she is good at, and maybe it will spill over into her Methodist problem. She is smart. She doesn't seem to be very visionary, but she is smart and she is knowledgeable and she is wonky. She could be a competent President. THIS IS EXACTLY THE TIME TO DRIVE THIS HOME! And the absence of Democratic opposition gives her the opportunity.

She needs to go deep into issues, and show how good she is. Pick out about seven or eight issues, not just a couple. She can concentrate on just a couple later on. But right now she can go into things she cares about and knows, and she doesn't have to cater to the current whims of the populace and address what they are concerned about now. The idea isn't to line up votes by agreement with issues – I doubt that happens so much anyway – the point is to show how competent she is, how experienced, how much she knows. The opposition won't have a chance to do that, they will be too focused on out-maneuvering one another. So while they throw elbows at one another, she can be very presidential.

Oddly enough, I would wager that this tack would actually make her more likable. Maybe not beer-buddy likable, but likable for her seriousness, for her caring, for the respect she shows the American people in treating them as adults.  In the end you are who you are, and the more you cop to that, the better off you are.

Anyway, that's my idea. Better than anything Mark Penn ever came up with.

Budd Shenkin

Saturday, April 4, 2015

Child Anxiety


As a pediatrician I have known that child anxiety is important to detect and talk about. I have seen a lot of anxious parents, and a lot of anxious children, and not very surprisingly, the two seem to travel together. I'm prone to anxiety myself, which is a pain, and I also seem to provoke it in myself. Somewhere I seem to think that if I'm not anxious, I'm not doing my job, or I won't do my job, or I won't get ahead.

Actually, I think I get it most from my father, although I could be wrong. I think I got it as I got older, but didn't have it at the start. As I think of myself in fourth grade, for instance, I can't remember being worried, or concerned, or anything, really. I remember mostly thinking that this is the best grade there is – we were the top grade in our assembly and I was the Student Council representative, but when we got to fifth grade we would be the youngest in the new assembly. So I was taking it for what it was – King of the Hill for the year. No anxiety there, none at all. That came later, mostly at college, I think.

But I digress. A pen pal of mine on the SOAPM listserve, Dick Schwartz, a veteran pediatrician from Virginia, posted this the other day. I liked it so much I'm passing it on here. With a thought. Isn't this important? If you took your kid to Dr. Schwartz, and he detected that your kid was anxious, and he pointed you to this way of dealing with it, wouldn't you be grateful? Don't you think this could change part of the course of childhood? Don't you?

And yet, do you realize that this detection, this conversation, this treatment, all of it, would go completely undetected by the Quality Police? The pediatric QP look for all sorts of things in a practice – immunization rates (important), lead testing rates (unimportant), chlamydia testing in teens (not very important) – lots of things that are (1) routine and (2) measurable. Surely, there is a need to measure quality, and if there is a need, there must be a way to do it. But is there a way? Well, there is and there isn't. You can detect some things, but some of the most important and life-changing things, are those you can't detect and you can't measure. So you have to rely on the professional diligence of your doctor.

Dick's patients are very lucky to have someone as diligent as he is. I was diligent, too. I like to think I made a difference for my patients beyond giving them shots, and maybe I did. I dunno. I hope I did.

But I digress once again. Let's just look at what is suggested for the anxious child. Makes a lot of sense to me.

Dealing with Child Anxiety? 9 Things You Can Try

by Renee Jain on March 24, 2015
Anxiety Relief for Kids GoZen

As all the kids line up to go to school, your son, Timmy, turns to you and says, “I don’t want to take the bus. My stomach hurts. Please don’t make me go.” You cringe and think, Here we go again. What should be a simple morning routine explodes into a daunting challenge.
You look at Timmy and see genuine terror. You want to comfort him. You want to ease the excessive worry that’s become part and parcel of his everyday life. First, you try logic. “Timmy, we walk an extra four blocks to catch this bus because this driver has an accident-free driving record!” He doesn’t budge.
You provide reassurance. “I promise you’ll be OK. Timmy, look at me… you trust me, right?” Timmy nods. A few seconds later he whispers, “Please don’t make me go.”
You resort to anger: “Timothy Christopher, you will get on this bus RIGHT NOW, or there will be serious consequences. No iPad for one week!” He looks at you as if you’re making him walk the plank. He climbs onto the bus, defeated. You feel terrible.
If any of this sounds familiar, know you are not alone. Most parents would move mountains to ease their child’s pain. Parents of kids with anxiety would move planets and stars as well. It hurts to watch your child worry over situations that, frankly, don’t seem that scary. Here’s the thing: To your child’s mind, these situations are genuinely threatening. And even perceived threats can create a real nervous system response. We call this response anxiety and I know it well.
I’d spent the better part of my childhood covering up a persistent, overwhelming feeling of worry until, finally, in my early twenties, I decided to seek out a solution. What I’ve learned over the last two decades is that many people suffer from debilitating worry. In fact, 40 million American adults, as well as 1 in 8 children, suffer from anxiety. Many kids miss school, social activities and a good night’s rest just from the worried thoughts in their head. Many parents suffer from frustration and a feeling of helplessness when they witness their child in this state day in, day out.
What I also learned is that while there is no one-size-fits-all solution for anxiety, there are a plethora of great research-based techniques that can help manage it — many of which are simple to learn. WAIT! Why didn’t my parents know about this? Why didn’t I know about it? Why don’t they teach these skills in school?
I wish I could go back in time and teach the younger version of myself how to cope, but of course, that’s not possible. What is possible is to try to reach as many kids and parents as possible with these coping skills. What is possible is to teach kids how to go beyond just surviving to really finding meaning, purpose and happiness in their lives. To this end, I created an anxiety relief program for kids called GoZen. Here are 9 ideas straight from GoZen that parents of anxious children can try right away:
1. Stop Reassuring Your Child
Your child worries. You know there is nothing to worry about, so you say, “Trust me. There’s nothing to worry about.” Done and done, right? We all wish it were that simple. Why does your reassurance fall on deaf ears? It’s actually not the ears causing the issue. Your anxious child desperately wants to listen to you, but the brain won’t let it happen. During periods of anxiety, there is a rapid dump of chemicals and mental transitions executed in your body for survival. One by-product is that the prefrontal cortex — or more logical part of the brain — gets put on hold while the more automated emotional brain takes over. In other words, it is really hard for your child to think clearly, use logic or even remember how to complete basic tasks. What should you do instead of trying to rationalize the worry away? Try something I call the
FEEL method:
Freeze — pause and take some deep breaths with your child. Deep breathing can help reverse the nervous system response.
Empathize — anxiety is scary. Your child wants to know that you get it.
Evaluate — once your child is calm, it’s time to figure out possible solutions.
Let Go – Let go of your guilt; you are an amazing parent giving your child the tools to manage their worry.
2. Highlight Why Worrying is Good
Remember, anxiety is tough enough without a child believing that
Something is wrong with me. Many kids even develop anxiety about having anxiety. Teach your kids that worrying does, in fact, have a purpose.
When our ancestors were hunting and gathering food there was danger in the environment, and being worried helped them avoid attacks from the saber-toothed cat lurking in the bush. In modern times, we don’t have a need to run from predators, but we are left with an evolutionary imprint that protects us: worry.
Worry is a protection mechanism. Worry rings an alarm in our system and helps us survive danger. Teach your kids that worry is perfectly normal, it can help protect us, and everyone experiences it from time to time. Sometimes our system sets off false alarms, but this type of worry (anxiety) can be put in check with some simple techniques.
3. Bring Your Child’s Worry to Life
As you probably know, ignoring anxiety doesn’t help. But bringing worry to life and talking about it like a real person can. Create a worry character for your child. In GoZen we created Widdle the Worrier. Widdle personifies anxiety. Widdle lives in the old brain that is responsible for protecting us when we’re in danger. Of course, sometimes Widdle gets a little out of control and when that happens, we have to talk some sense into Widdle. You can use this same idea with a stuffed animal or even role-playing at home.
Personifying worry or creating a character has multiple benefits. It can help demystify this scary physical response children experience when they worry. It can reactivate the logical brain, and it’s a tool your children can use on their own at any time.
4. Teach Your Child to Be a Thought Detective
Remember, worry is the brain’s way of protecting us from danger. To make sure we’re really paying attention, the mind often exaggerates the object of the worry (e.g., mistaking a stick for a snake). You may have heard that teaching your children to think more positively could calm their worries. But the best remedy for distorted thinking is not positive thinking; it’s accurate thinking. Try a method we call the 3Cs:
Catch your thoughts: Imagine every thought you have floats above your head in a bubble (like what you see in comic strips). Now, catch one of the worried thoughts like “No one at school likes me.”
Collect evidence: Next, collect evidence to support or negate this thought. Teach your child not to make judgments about what to worry about based only on feelings. Feelings are not facts. (Supporting evidence: “I had a hard time finding someone to sit with at lunch yesterday.” Negating evidence: “Sherry and I do homework together–she’s a friend of mine.”)
Challenge your thoughts: The best (and most entertaining) way to do this is to teach your children to have a debate within themselves.
5. Allow Them to Worry
As you know, telling your children not to worry won’t prevent them from doing so. If your children could simply shove their feelings away, they would. But allowing your children to worry openly, in limited doses, can be helpful. Create a daily ritual called “Worry Time” that lasts 10 to 15 minutes. During this ritual encourage your children to release all their worries in writing. You can make the activity fun by decorating a worry box. During worry time there are no rules on what constitutes a valid worry — anything goes. When the time is up, close the box and say good-bye to the worries for the day.
6. Help Them Go from What If to What Is
You may not know this, but humans are capable of time travel. In fact, mentally we spend a lot of time in the future. For someone experiencing anxiety, this type of mental time travel can exacerbate the worry. A typical time traveler asks what-if questions: “What if I can’t open my locker and I miss class?” “What if Suzy doesn’t talk to me today?”
Research shows that coming back to the present can help alleviate this tendency. One effective method of doing this is to practice mindfulness exercises. Mindfulness brings a child from what if to what is. To do this, help your child simply focus on their breath for a few minutes.
7. Avoid Avoiding Everything that Causes Anxiety
Do your children want to avoid social events, dogs, school, planes or basically any situation that causes anxiety? As a parent, do you help them do so? Of course! This is natural. The flight part of the flight-fight-freeze response urges your children to escape the threatening situation. Unfortunately, in the long run, avoidance makes anxiety worse.
So what’s the alternative? Try a method we call laddering. Kids who are able to manage their worry break it down into manageable chunks. Laddering uses this chunking concept and gradual exposure to reach a goal.
Let’s say your child is afraid of sitting on the swings in the park. Instead of avoiding this activity, create mini-goals to get closer to the bigger goal (e.g., go to the edge of the park, then walk into the park, go to the swings, and, finally, get on a swing). You can use each step until the exposure becomes too easy; that’s when you know it’s time to move to the next rung on the ladder.
8. Help Them Work Through a Checklist
What do trained pilots do when they face an emergency? They don’t wing it (no pun intended!); they refer to their emergency checklists. Even with years of training, every pilot works through a checklist because, when in danger, sometimes it’s hard to think clearly.
When kids face anxiety they feel the same way. Why not create a checklist so they have a step-by-step method to calm down? What do you want them to do when they first feel anxiety coming on? If breathing helps them, then the first step is to pause and breathe. Next, they can evaluate the situation. In the end, you can create a hard copy checklist for your child to refer to when they feel anxious.
9. Practice Self-Compassion
Watching your child suffer from anxiety can be painful, frustrating, and confusing. There is not one parent that hasn’t wondered at one time or another if they are the cause of their child’s anxiety. Here’s the thing, research shows that anxiety is often the result of multiple factors (i.e., genes, brain physiology, temperament, environmental factors, past traumatic events, etc.). Please keep in mind, you did not cause your child’s anxiety, but you can help them overcome it.
Toward the goal of a healthier life for the whole family, practice self-compassion. Remember, you’re not alone, and you’re not to blame. It’s time to let go of debilitating self-criticism and forgive yourself. Love yourself. You are your child’s champion.

Simple tools can help alleviate your child’s anxiety. Start teaching your child coping skills with animated lessons here.

This was originally posted on PsychCentral as 9 Things Every Parent with an Anxious Child Should Try
 

Isn't this important? And where will you get help except from your primary care pediatrician? Yup, primary care. The same pursuit that some health policy people are trying to run out of business with High Deductible Health Plans. But I digress. Time for me to get back to preparing my upcoming presentation to the Goldman School of Public Policy Board of Advisors on High Deductible Health Plans. That's making me anxious.


budd shenkin

Thursday, April 2, 2015

The Health Care World is Looking for a Hero




Everyone is familiar with the basic problems of health care in the United States. It costs a lot, it is inefficient, and quality is highly variable. With these problems, virtually everyone in the field, liberals and conservatives, agree on the so-called “Triple Aim” of health care reform: decrease the rate of change of the cost increase (bend the cost curve) if not actually decrease the cost; improve the consistent quality of care; and improve the health status of the population at large. In theory, this should be doable with better organization.

There are a few programs in place trying to achieve cost reduction, hopefully while also achieving the other two objectives. Accountable Care Organizations are one such program. Another is an attempt to change the fee for service mode of payment and replacing it with so-called Value Based Insurance Plans, which would generally pay a set amount for various conditions, and so put the onus on practitioner organizations to make their services cost-effective. But the most advanced and widespread program of cost reduction is health insurance called High Deductible Health Plan (HDHP). I have explained my opposition to HDHPs before on this blog with some passion. I was also lead author of the American Academy of Pediatrics policy paper criticizing HDHPs – http://pediatrics.aappublications.org/content/133/5/e1461.full.pdf+html. These plans accounted for over 20% of employer-sponsored health insurance policies in 2013, and that percentage has doubtless markedly increased under the ACA (Obamacare).

The key result of HDHPs is to decrease the volume of health services at the lower level of care – primary care especially, but lots of other basic services as well. In other words, its effect is to cut utilization and thereby to cut costs. The most prominent pro-HDHP article I'm aware of appeared a couple of years ago in the journal Health Affairs; written by Amelia Haviland et al., its title was “Growth Of Consumer-Directed Health Plans To One-Half Of All Employer-Sponsored Insurance Could Save $57 Billion Annually.” Pretty assertive. Now a followup article has appeared: “Do consumer-directed' Health Plans Bend the Cost Curve Over Time? “ The conclusion is yes, they do. Amazing. If you raise the price of a service people consume less of it. Bring on the Nobel Prize. And try to ignore the other two elements of the Triple Aim, quality and health of the community, because with HDHPs quality and equity have to decline.

But health care costs do need to decrease, and the HDHP advocates are doing the research necessary to show that, whatever the defects of HDHPs (and I think they are severe), at least costs are reduced, or so it seems at present.



The is this: yes, HDHPs are poor policy, but where is a better substitute? We don't have compelling alternatives, for many reasons. So, to try to fix the problems responsibly, we have to take preliminary steps to help these alternatives to appear.



So, here is my suggestion for the research someone should undertake. It would be easy research, it would be significant research, and it would be great for someone's career. Here's my suggestion:



We have good evidence that a major problem with the US health care system is not over-utilization, but over-pricing.  See tinyurl.com/pz7oumm.  Here is an example: in 2012, the average hospital day in the US cost over $4,287.  The next highest hospital day cost in international perspective -- not the average international hospital day cost, but the next highest -- was Australia, where the cost per day was $1,472.  That's not a small difference.



This shows just one item of comparison, the cost of a hospital day. This same report shows many, many items wit the same order of difference. The average price for an angiogram in the US was $2,430.  In Chile, the next highest country, it was $378. Given these differences, how can one think anything else besides, what would happen to US health costs if the prices of medical goods and services were in line with the rest of the world?



So, that's the research project. Do the same thing the first Haviland article did. Take about 20 of the common and overpriced services. Compare the cost of all these services together and see how much they cost now, and how much they would cost if they had international prices. Here's the matrix:

-->


annual frequency average US price x times y = total cost
CURRENTLY




Service 1 x $y $z

Service 2 x’ $y’ $z’





Service 20 x’’ $y’’ $z’’

TOTAL

TOTAL COST 1








average intl. Price x times i = total revised cost
REVISED Service 1 x $i $m

Service 2 x' $i’ $m’





Service 20 x’' $i’’ $m’’

TOTAL

TOTAL COST 2






AMOUNT SAVED = TOTAL COST 1 - TOTAL COST 2



Then publish the paper in the mode of the first Haviland article: “Curtailing the Price of 20 Common Medical Services to International Norms Would Save $100 Billion in the US.”



Say the Amount Saved turned out to be really significant, as I think it would be. Then, although we wouldn't have a program that would be competitive with HDHPs, we would have a target. Find a program that would reduce the prices of key overpriced services, and there it would be, a program that decreased costs without interfering with quality of care. Yes, it would be hard to find that program, but at least the target would be clear and present.



That's my proposal. The medical cost world is looking for a hero. Somewhere out there, that hero is waiting. Hey, read my blog!



Budd Shenkin