Wednesday, September 20, 2017

Budd Shenkin's Buzzy Award Remarks








Life is strange, the way things work themselves out. One of my favorite lines comes from Kurt Vonnegut's Sirens of Titan, which I misremember as “I am here because of a series of accidents, as are we all.” It's actually “I am the victim of a series of accidents, as are we all,” but somehow I like my mis-memory better. No life plan, no God's plan, just randomness working its way. As Vonnegut also says in Slaughterhouse 5, “So it goes.”

I got to use that line last Saturday, even though it wasn't in my script but only in the back of my head, and I was so pleased. At last. The way things worked out for me, after I became a pediatrician not knowing if I really wanted to practice medicine, and in fact hadn't envisioned myself being a pediatrician until I found myself (in both senses of the word) on the pediatric wards, and after I found myself running a practice that became a big group, the way things worked out was, after thinking I didn't mesh comfortably with American Academy of Pediatrics, and I didn't mesh comfortably with my home academic university UCSF, the way things worked out was, I found SOAPM, where it turned out I did mesh very well. I found it when a competitive local colleague who was trying to build SOAPM membership and didn't really have my welfare in mind, mentioned to me that SOAPM existed within the AAP and “you should join it.” SOAPM stands for “Section On Administration and Practice Management,” which is what I found the most challenge and pleasure in doing, administering my practice. And so it goes.

So there I was standing before the group of maybe 150 at the convention center in Chicago accepting the annual Buzzy Vanchiere Award, conferred by SOAPM for excellence and service, and I used the line. SOAPM had become my home, where I had served on the Executive Committee for six years, and where I had figuratively sweated and bled for probably 15 years, and where I had found my place. Because of a series of accidents.

As I started my remarks, I noted that the Buzzy Award confers three things. One is what I chose to see as love and respect from my SOAPM colleagues, which I reciprocated enthusiastically – “back atcha!” Seriously, these are wonderful people and some of the best friends of my life. The second Buzzy thing is a $1,000 honorarium, which I am forwarding on to the AAP Building Fund, which I am more than happy to do as a sign of support and respect to the AAP (with more to follow, actually.) And the third thing is: a semi-captive audience. As I noted this, there was a small laugh, perhaps nervous.

An audience. No set subject. What to say? That was the question.

I think a lot about the health care system, and my first impulse was to give a speech about the evolving organizational structure of medicine (see http://buddshenkin.blogspot.com/2017/06/policy-for-emerging-organizational.html)
and the weaponization of EMR's by academic health centers to augment their power and control. But as much fun that would have been for me, not necessarily so much for the audience. So I discarded that idea, other reflections and recollections, and bon mots, and I focused. And what I finally focused on was SOAPM itself. As I thought more and more about it, as I thought about how SOAPM had evolved, and as I thought about the challenges facing the AAP and American medicine, the more I thought that I had something to say about how SOAPM should view itself, and what SOAPM should do, and what the AAP should do. And that became my talk.

So, here it is, my Buzzy talk, edited for readability, and missing some spontaneous emissions when I spoke it, some of which evoked applause and some laughter. But the essence of the message is what we're interested in here.

It got a good reception when I gave it, lots more in the next couple of days, and I hope it leads to action. Now, that would be a real dividend from the Buzzy award.


Budd Shenkin's Buzzy Talk
September 16, 2017
AAP NCE, Chicago, IL

Here in brief, is the message of this address:

SOAPM is a lot more important than we might think it is. It has far exceeded the objectives that the founders of SOAPM hoped for it, and then has gone far beyond them. Given the great changes of organizational structure that the medical world is experiencing, and given the evolving requirements for the AAP to be effective in that medical world, SOAPM is not just another AAP section. It is now more relevant to both the AAP and to the evolving world of health care than anyone could have predicted.

When this happens to an organization, when it becomes very successful and when the world it addresses changes, one has to reassess the organization’s structure and the resources devoted to it. Just so with SOAPM. I believe that SOAPM needs to be reevaluated, to be strengthened, and that our basic organization probably needs to be updated.

Because I think it's possible that, great as SOAPM is, you ain't seen nothing yet.

To make that case, briefly, I intend to look at the past, the present, and the future.

What we have done so far

SOAPM has been a roaring success.

  • We have increased our membership to over 1,200, and we are arguably the most dynamic section or committee within the AAP.
  • I don't know if the founders would be surprised or not, but I'm certain they would be gratified.

The Original Agenda

I think the SOAPM founders hoped that the section would:

  • concentrate on helping each other run practices.
  • educate the rest of the Academy on how to do it.
  • and show the Academy how important administration and management is.

This is still mostly what we do.

  • We help with coding.
  • We trade tips about how to organize our offices.
  • We coach on how to deal with insurance companies
  • We give lots of educational sessions on management topics – Herschel himself has become a virtual education industry.
  • We have constructed a huge storehouse of documents on how-to.
  • Not to mention that we are the world's leading repository for vaccine-refrigeration and disaster preparedness information at our subsidiary office in North Carolina.

I think this was the original agenda. No doubt we have exceeded hopes and expectations.

Possibly part of the original agenda

It's hard to know if the founders envisioned this, but SOAPM has been successful in helping Academy statements and projects to be practical and relevant. There are innumerable instances where this has happened, but just to name two:

  • No unfunded mandates – want us to do some things for Bright Futures? OK, we have to be paid to do it.
  • Practice responsibilities for vaccine refusing families – we now have freedom to refuse them as patients, and as a result we think many more families will be vaccinated.

Probably not part of the original agenda

Amazingly, SOAPM has been able to help the Academy recognize a new facet of its mission. Traditionally and appropriately, the Academy has stood fast in its determination to improve the health of children. Now, even though we recognize that the Academy is not a trade association, it is now considered legitimate that the Academy consider protecting and improving the health of our practices as part of its mission. The health of pediatrician practices, whether independent or within networks and groups, is now recognized to be strongly connected to the health of children. That is thanks to SOAPM. We have exceeded the original vision here.

Also probably not part of the original agenda

SOAPM has also exceeded its original charter by reaching out to try to affect the actions of organizations external to the Academy.

  • Trying to influence NCQA and make their measures palatable to pediatricians seeking to qualify as Patient Centered Medical Homes.
  • Trying to help CDC improve flu shot distribution.
  • Trying to rationalize the VFC program.
  • Trying to help Feds get coding straight.
  • Trying to get the American Board of Pediatrics to straighten out its act.
Truthfully, we have been only partially successful in these efforts, and SOAPM and the Academy are still not sure how assertive to be. But we seem to be on the road to becoming more successful.

Certainly not part of the original agenda

There's one thing they couldn't have envisioned in founding SOAPM – the listserve, because the technology wasn't there yet. The listserve has proved to be the X-factor that has multiplied the impact and importance of SOAPM immeasurably.

We use it:

  • To fulfill our main mission, to trade knowledge and views on practice administration, on interventions with insurance companies, on coding, etc.
  • To trade clinical information, which is so enlightening and so much fun.
  • To trade information on outrages by everyone, from government to patients and not excluding the Academy.
  • To trade opinions.
  • To keep up with and deepen our knowledge of policy
  • Etc.

And then there's something much deeper that the listserve has gifted us with, besides making sure that we “get mail.”

The listserve is what has led us to become a great virtual community. We are a community. We care for each other, we reach out to each other, we have come to know each other and help each other, and to forge bonds of affection born of discovery. We feel about each other: where were you all this time I've been looking for you?

And, the listserve has uncovered great intelligence and talents. Aren’t you just blown away by some of the things we hear that people are thinking? We have so many smart people here. And idealists. Yes, make sure we are paid for what we do – but the true idealism of people, the embodiment of the true mission of medicine, of pediatrics, shines through. You are some of the finest people I have ever known. SOAPM is a testament to the power of a listserve!

So, this is only a partial list of activities and accomplishments. SOAPM has been, and continues to be, a roaring success. We have punched far above our weight. We are all so blessed to be part of it.


The Future Agenda, and Our Organization – Aspirational Goals

KEY POINT: Even as successful as we have been, SOAPM could actually be even more than what we have become. Our task at this point, I think, is to envision our future.

First Point

Health care’s organizational structure is changing very profoundly and quickly. Everything is getting much more agglomerated and corporatized. This presents us with a very potent challenge. New entities are arising, such as RBC’s and UC’s for after-hours care, networks, other agglomerative bodies. And in fact, we need to recognize that over half of us are now employed physicians! Not that there's anything wrong with that. Employed pediatricians aren't that different from those of use who are independent. The majority of pediatricians are eager to serve patients well, and to improve the systems that they are part of, and to make sure that they themselves thrive in the process.

But while increasing size can be good, it is also a threat.

  • It's a threat to patients – bureaucratic medicine can be harmful to your health.
  • It's a threat to us – some of us would rather quit than become a cog in a corporate wheel.
  • And to those of us who are working in larger systems, we need a lot of help in coping with the bureaucracy that we are part of, to survive happily, and to improve the systems of care that we are part of.

With all this change, where is the voice of primary care pediatrics? Where is the voice of primary care that knows organization, administration, and business? Nowhere else but SOAPM. We are much more important than we realize, and more important than others realize.

Recall the Indian parable of the blind men trying to describe the elephant. One of them says, “An elephant is a round, very heavy immobile post.” Another feeling the ear says, “No, it is thin and long and floppy.” A third says, “No, it is long and round, flexible and strong, with a hole in the middle.” To understand what an elephant is like, they have to communicate and to accept what the other is saying, without the arrogance of thinking that they are the only one who is right.

What is the point of view that SOAPM has to contribute to the ongoing puzzle of reforming the health care system?

We have a point of view that is invaluable. We are where the rubber hits the road, since we actually see patients day after day, not two half days a week; we are the ones who devise the processes and implement in real time what others only imagine; we see what is actually happening as a result of policies. We know how to design systems that work.

Yet we struggle to get our voices heard, within the AAP, and in the larger medical world. Other forces are very powerful – from insurance companies, from PhD's and MBA's, from hospital administrators, from the large academic centers, from the procedural specialists. They have the arrogance of power and money. They really don't want to hear us. So we have to insist.

We need to be at the table and not on the menu! We are important and we shouldn't have to fight our way into every discussion, into every policy argument. We shouldn't be treated like step-children. The AAP should be bringing us in on just about everything, not just having things handled by a few Board members and some top staff. On SOAPM'S behalf, I want in, and I don't want to have to fight for it.

A case in point is policy on after-hours care units, RBC's and UC's. Jim Perrin tried to bring order out of chaos by developing a policy centered on the Task Force on Pediatric Practice Change, and did a good job, but then the TFOPPC's sun set. Currently, this policy just goes floating around – this policy needs a home, and it should be with us. That's just an example. More generally, the Academy needs a center to consider issues that arise on the organizational structure of health care, and I nominate SOAPM to fill that vacuum.

In sum, in these new times, SOAPM is more important than ever.


Second Point

If we are going to meet this challenge, we need to consider our own internal organization. While the world and our functions have changed dramatically since SOAPM was founded, we are still organized exactly the way we were twenty years ago, and we still have the same resources.

For one thing, we need to run SOAPM like a business! This point has been made most cogently by Jeanne Marconi and Sue Kressly on the EC. We don't need to reorganize to make money – that's not the point. (Although business is our business. We wish the Acadmy would turn to us for some business advice instead of hiring consultants – that's another function we could serve.) But we need to have agendas, a list of things we want to accomplish and means to accomplish them with timelines, on objectives that are widely accepted within SOAPM. We all in SOAPM should be aware of our agenda and have a chance to help shape it. And it should be visible to and approved by the higher administration.

We also need to make better use of our member resources. Jon Caine and Glenn Schlundt, Peter Pogacar, members of the EC, so many others, so smart! Yet, the discussions and analyses just vanish into the electronic ether of the listserve. They shouldn't! We have huge intellectual resources that are being suffocated here within SOAPM. (At the very least, by the way, our journal Pediatrics should modernize itself and have a section devoted to policy and management articles.)

The mark of an excellent organization is one that identifies, nurtures, and makes use of the excellence in its workforce. We need to organize ourselves so that we do that effectively.

Maybe it is no longer appropriate that SOAPM should be a section. I'm not sure what other form we should take, but we should be immediately accessible to the Board and the CEO, and we should be able to be the repository for policies concerning organization of care and be able to produce policy papers.

More generally, the policy world is crying for primary care leadership, and we should press the AAP to use us to supply that leadership.

We will need more resources for this – we actually need more resources just to continue what we are already doing.

For us to achieve a new organizational form and placement, we need a first action step. I propose that we establish a task force of 10-15 people, from SOAPM, from the Board, and including a representative of the CEO, to reexamine the structure and function of SOAPM and come up with alternatives for the future.

We have grown; now we need to differentiate. An organization that is not going forward is going backward. Let's not be like Kodak - they owned the world of imaging for a hundred years.  But they took their eye off the future of their industry and quickly became irrelevant.

Finale

So, my message is simple. We have been a great success. We have given to ourselves, we have given to the Academy, we have given to our patients. But it's time for us to think bigger. What more can we do with more staff, more involvement from our membership, a more prominent place in the AAP, a more businesslike organization?

I say, let's give it a try.

Budd Shenkin


Sunday, August 20, 2017

Do The Democrats Belong In The Major Leagues?


I believe there is very little in life that cannot be illuminated by a reference to baseball, and if not baseball, then basketball.

Take our political situation. Our team is the Democrats. We can love them, we can hate them, we can hold grudges – my grudge against Hillary and the other Clintons hasn't shown signs of weakening, and I voted for them but I think no matter the opposition I would vote against $50 millionairess Chelsea, since even home team allegiance has limits – we can deplore their ineptitude, but they are our team. We can admire players on the other team, from time to time, but the admiration always has to be somewhat grudging, because they are the opposition. Mantle was great, but not ours. Ted Williams – well, there's the exception, especially because he was always so beleaguered, he was called back to service for the Korean War for God's sake, and he never won it all.

But anyway, when you are losing badly, the dreaded word “rebuilding” comes up from the depths. Can anyone be more in the depths than the Dems? Statehouses, state legislatures, House, Senate, Presidency, and the stolen Supreme Court? All gone, ladies and gentlemen, all gone. How can you not think, “rebuilding time!”

How did we get here? I indict Hillary and the Clintons, of course, that's an easy call. Ineptitude, here is your avatar, losing an unlosable election by playing – OK, switching sports – a prevent defense, for God's sake. We all know by now that a prevent defense prevents winning. I'm still getting posts on Facebook of Hillary warning against Trump. Yes, she was right, of course she was right. But it was still a stupid thing to do. Your mean teacher warning you – that's sure a winner. Just as it was stupid for Hillary and Bill, with their famous long memories and penchants for revenge, to squash any young pretenders of any possible support, so the only challenge came from Bernie. Yes, he did a great job, but come on, can you think that one-track Bernie, right as he may be on that single track, is the future of the franchise? A great free agent from the land of the Independent, admirable, an amazing season, it would be great to see him do something again, but the future? Maybe a guide, but not the strong shoulders to lift everyone up, not a Mike Trout to build around. But he was all that was left.

Strong leaders build strong teams. They go out and recruit the Kevin Durant and pledge to play together and love one another. They don't protect themselves by bringing on dwarfs like Debbie Wasserman-Schultz. Yes, Hillary looked like the charming one in comparison to ol' Debbie, but come on, man.

And much as we love and admire BHO – I don't think that set of initials is going to stick as well as, say, KD (love KD!) – he didn't build a strong legacy. He didn't educate the country, he didn't as they say “change the conversation,” he didn't find the great leaders and promote them. He stuck us with Hillary, sorry to say. He doesn't seem to be gregarious, he hung out with young staff guys and his golf crowd, so how could he find out who was a hot comer? He couldn't even remember Pete Buttigieg's name when asked for the possible rising stars, calling him “the Mayor of South Bend, that guy” – Bill Clinton would know his name and his boyfriend's name, how to seduce him politically, what his weakness was, and would have found him a role and made sure he wasn't threatening – but that was his weakness, not strengthening people.

Obama left us with very little. Maybe it's not his fault, but I think it really is. Great guy with many weaknesses, and one of them was not making use of his great strength of expression. Where were the great speeches building a program legacy? Where were his close allies ready to take charge? Maybe he'll come through now, maybe. He's so smart and he can really learn.

OK, so we're rebuilding. When teams rebuild, they look to their farm system, and they trade for the future. Well, trading's not something to rely on in politics, but the farm system, that's where you have to look, and you have to recognize when the old team is lagging. Nancy and Steny might still have knowledge and strength, but they're losing, so time to pack up. Sorry. Nice job.

To find the new stars, there's no way to tell who can do it without putting them in the batter's box. This is the time, just like when the current season is gone, put the young guys in and see who can throw strikes for outs and who can hit major league pitching. With the midterms lurking, it's time not only to see what candidates can run well in the districts, but higher up in the order, who can go around to the districts and give speeches for those guys and gals, who can make the good connections on a personal level, who can strike the right notes, hit the singles and doubles all across the country and head for the middle of next year's lineup. It's tryout time.

Trump is throwing a fastball right across the middle, and his team can't get rid of him with his unbreakable contract. Now, who on our Dem team can hit those pitches out of the park? Somebody should be able. We're looking around for them. We see them coming through MSNBC, and then we'll see who can go around to the various ballparks and prove they belong in the show.

The message? They'll have to form the message. We know the outline; the stars will have to fill in the blanks and express it their way. The ownership can't do it – “A Better Deal” proves that point. We'll see how the show gets formed on the road, to mix show biz into the analogy. You find the stars, and then you field the team around them. Politics should be a team sport.

There is no guarantee that the team will assemble itself into a winner, of course. There is an opposing team, and they have journeymen masquerading as stars, I'd say – but they are familiar by now and well on their way to winnowing down to their strongest. And the old line Dems could still hold sway. I'm from Philadelphia, and any fan from Philly knows how to suffer. I remember Connie Mack. In those pre-free agency days Mack not only managed the A's, he was the owner, so he couldn't be fired. Decades of frustration were the product of stagnation. What did he care? The A's were “his team.”

Ownership is key to winning; look how the derelict Warriors transformed themselves when the Milwaukee group bought them and hired Don Nelson in the 80's, and how the story repeated itself in spades these last five years to produce one of the finest teams ever. Not only ownership willing to spend, but ownership willing to bring in Jerry West and to listen to him, to bring in Bob Myers and let him operate, ownership willing to play the true ownership role.

Ownership in politics has changed from the years of Bob Strauss and the backroom boys. I'm not sure how it works now. But in the end, either the old Dems will keep holding sway, or a new group of owners will emerge to identify the stars and produce an organization that actually functions, unlike the DNC who couldn't even respond when they found they were being hacked. Seriously, they couldn't. And they couldn't bring out the voters who would make a difference in Milwaukee, in Philly, in Michigan. What a horrible organization. (I wish they would stop calling our home for donations, Jesus, enough already! We're not giving you a cent! Or at least I'm not; I can't speak for Ann. She's probably more level-headed than I am.) But maybe Bernie and Obama can make peace and with a few others – please keep Hillary out! – see which of the youngsters is hitting and give them the support they need.

So, that's the deal now. Who can find the right balance of decrying the Republicans and offering a vision of hope and progress that makes sense, who can go to the ballparks across the country and keep getting hits? And when the stars emerge, as they will, can there be an ownership to guide them into a team that brings all the strengths together?

Remember, Cornelius McGillicuddy's A's eventually moved to Oakland with a different owner and produced some of the finest teams in history. They actually rebuilt under new ownership, and the result was, as they say, history. I can't say that I still don't hold a grudge against Connie Mack, and against Hillary, but there's nothing like winning to take the edge off.

I'm ready for the new season. More than ready. But if they mess it up again, then you finally have to say, we need a new team to be able to compete in the Majors. I'm hopeful it doesn't come to that.

Budd Shenkin

Monday, August 7, 2017

The Weight of Ink, by Rachel Kadish





Sometimes, you just don't where it will come from. My favorite book for this summer is The Weight of Ink by Rachel Kadish. The name “Kadish” is probably not familiar to you, but it's the name of one of my best friends in medical school, Larry Kadish. We were guards together on many a basketball team. We worked well together, mutual respect and affection. He told me, one of the great compliments of my life, that I could be hung over, exhausted, or sick, no matter, I would always get my points. How can I not love Larry?

Then, halfway through med school he married one of our classmates, Anna Stein, from New York, but before that from Holocaust Poland to the US through the Eastern route. At our reunion in June, I told Anna that I played cards with a fellow Jewish pediatrician who was from Shanghai originally, and I had told him that my classmate Anna had escaped through China. “Japan,” she said, “but close enough.”

I still feel a little guilty that when Anna went into labor and I had volunteered to stay with Larry while she was in labor – in those days I had the idea that men stayed outside the delivery room and smoked, although neither of us did, but maybe we would – but when she went into labor I was at home in Philadelphia and missed my support role, which was big in my eyes. I called Larry a few years ago to apologize, get it off my chest. “That's OK,” said Larry, “I really don't remember anything about it (about my promise to be there, not the birth).” Maybe I wasn't as central to that story as I thought I was.

So, Larry and Anna have a daughter, Rachel. I don't even know which child she is, 1, 2, 3, or 4, but she's in there somewhere. And it turns out she is a writer of novels. They have admirable restraint and didn't go all around the reunion saying that their daughter's book was coming out, after 12 years of working on it, at least not to me, but Ann finally couldn't help it, she posted the link to a New York radio interview of Rachel on our class listserve, not saying anything, just posting it. (www.wnyc.org/story/weight-ink/)

Out of loyalty to them I felt I had to listen, and the book sounded interesting and she sounded charming and intelligent and winning, although if she weren't their kid I wouldn't have voluntarily picked up a book about a blind Jewish rabbi and his female scribe in 17th century London. But I then ordered it on Amazon and put it ahead of finishing my current book, the newest Hitler biography (it's very good – hadn't really understood at all about the Beer Hall Putsch and Weimar Germany).

But then as I read, I found that I couldn't put it down. It's just one of those books you hope to find, a book that you hurry through to the end because you can't put it down but that you don't want to really end. A book that you want to keep with you if you can, maybe just to be able to look at its cover. Twelve years, and it reads not at all like the ponderous title of weighty ink, but flowing sentences, good sentences, and an intricate plot that connects all the way through – at least I think it does, I'm not real good on plot lines.

It's one of those books that alternates chapters of two different stories that are connected. One is the accidental discovery in 2001, in a house dating from the 17th century, as it is being redone and updated to greet the public as a museum, of a set of manuscripts from that period. The owner calls his old medieval history professor, Helen Watt, a seemingly severe English woman about to retire, who we find has a history of being a gentile in the new Jewish land of Israel where she fell in love with an Israeli and loves him still, although in absentia, since it didn't work out. She recruits an American Jewish doctoral candidate, Aaron Levy, to help her. Both are fluent in English, Hebrew, Portuguese, and Latin, I think, and they piece together the meaning of the documents and the history of the people, as they battle in the competitive academic bureaucracy. It is the find of a lifetime, this set of manuscripts of the letters of the rabbi and household accounts. Gradually they piece together the story.

We, however, know much more than they do, because every other chapter traces the life of the rabbi and, more centrally, the scribe, Ester Velasquez, both of whom were exiled from Portugal, the rabbi blinded by the Inquisition, then to Amsterdam, and thence to London in the continuing diaspora. London accepted Jews under Cromwell, perhaps for the business, perhaps because the Bible foretold that the Messiah will appear only when Jews are everywhere. A great picture of what life must have been like for these Jews, the women working hard in the houses and aspiring to little but husbands, the wealthy and the poor living very different lives, the continuing value of learning, life as it must have been lived in the Interregnum and the Restoration. But the excitement of the 17th century story is not only the personal stories – which are good – but the intellectual progress of Ester, and through her, letting us see what the Jews were thinking about, and contending about. Letters go out to many of the well known intellectuals with Ester's razor-sharp questions and logic, to be answered by some, including Spinoza. She resists marriage as it would be a cage, at least until the great plague, and then the fire. It's a compelling, compelling story.

Helen and Aaron, meanwhile, have their own trials to endure, they own paths to follow, their own dilemmas to be faced, their own characters to be probed. The introverted English and the extroverted American, familiar territory, but wonderfully evolved. And in both parallel stories, there is so much of the lives of women, and men, and the process of choosing a mate for feeling and the risks of doing so, and chance, and the continuing story of the Jews, of whom I am one but of which I know so little. I knew in theory what a feat it has been to keep a people alive as a people for eons without a homeland to live in, but this book lets me see that a lot more clearly. It's a serious book, but an intimate one, with continuously touching stories, the kind where you want to break the fourth wall and talk to them. This daughter of Larry and Anna can write.

And then I finished and I reread the comments on the book cover. The front cover has from Toni Morrison: “A gifted writer, astonishingly adept at nuance, narration, and the politics of passion.” I hadn't thought about passion having politics, but now that she points it out, I guess that's right. The back cover has compliments from five authors, and it was only at that point that I realized they were all women. What I had read and loved was a feminist book! Yes, I realized all the way through that she did women better than men, but I hadn't realized that so much of what she was writing about was the plight of women, and the over-weaning nature of so many of the men, although there were good ones, to be sure. But we don't see them as intimately as the women. How come I didn't notice?

Well, I don't notice a lot of things, and when it comes to fiction, I'm no expert, I'm more of an “I like it” kind of guy. Although when pressed, I guess I can hold my own. And I do hope I get pressed on this one, because I think it's a deep, rich book, one that can stand a lot of examination and discussion, and a lot of love.

I wish I could say that is the child whose birth I missed, but probably not, probably a later one. But whatever, even though I don't see them much, these are my dear friends, my classmates, and they have birthed and nurtured someone who has worked so very hard at her craft to be able to produce such a book, and worked very hard to learn enough to produce this very one. As I wrote to Larry and Anna when I was on about page 75, I think this should be a National Book Award contender. I'll stick with that.

Larry, it might be true that I will always get my points, but Rachel has just racked up a lot more than I ever could.


Budd Shenkin

Wednesday, July 19, 2017

Why Does The Crowd Still Support Trump?


So, why does Trump still have so much support among Republicans and “his base?” When it's obvious to so many of us how ineffective and embarrassingly gauche he has been, when his paper-it-over lies are so obvious? Why?

Well, that's the way mass psychology goes. Take the stock market, which like politics is another exercise in mass psychology. In both politics and the market, you can go quiescently along for a while, and then you are forced to make a choice. Elections force a choice upon people, just as when you have money in your account and you need to be in the market, you need to buy something. Then, when you buy, you tend to hold. You tend to keep your bet until you are forced to make another choice. No one likes to admit a mistake; a naïf tends to hold a stock to the bitter end, and it can be bitter, hoping it will come back. For that matter, a naïf is likely to hold a stock even when it goes up, until it comes down to the level where it was bought, where it is sold so the holder doesn't suffer a loss. This is called a “round trip.” Lucky are they who have the fortitude to sell with a nice gain, or to sell with a mild loss before the collapse. All good things come to an end, but not everyone recognizes it in time. And there is always somebody who buys at the top.

It's not only the market. The Giants took fully half a season of being the second worst team in the majors to finally have a night with less than a sellout crowd, for goodness' sake. And Mr. Trump's supporters, who are inattentive to politics most of the time and who are often incapable of analysis even if they are attentive, are holding onto their stock even as it palpably weakens and the smart money is bailing, quietly, out of the limelight, leaving it to the public to take the hit.

Mass psychology, of course, is built on personal psychology. I've just been reminded that Danny Kahneman, he of the Nobel Prize, investigated this issue formally and brilliantly, and Dave Leonhardt in the NYT supplied this link:


Here is the introduction:

A wine-loving economist we know purchased some nice Bordeaux wines years ago at low prices. The wines have greatly appreciated in value, so that a bottle that cost only $10 when purchased would now fetch $200 at auction. This economist now drinks some of his wine occasionally, but would neither be willing to sell the wine at the auction price nor buy an additional bottle at that price. Thaler (1980) called this pattern-the fact that people often demand much more to give up an object than they would be willing to pay to acquire it-the endowment effect. The example also illustrates what Samuelson and Zeckhauser (1988) call a status quo bias, a preference for the current state that biases the economist against both buying and selling his wine. These anomalies are a manifestation of an asymmetry of value that Kahneman and Tversky (1984) call loss aversion-the disutility of giving up an object is greater that the utility associated with acquiring it.

It continues:

The Endowment Effect

An early laboratory demonstration of the endowment effect was offered by Knetsch and Sinden (1984). The participants in this study were endowed with either a lottery ticket or with $2.00. Some time later, each subject was offered an opportunity to trade the lottery ticket for the money, or vice versa. Very few subjects chose to switch. Those who were given lottery tickets seemed to like them better than those who were given money.”

In other words, do we really expect people, generally untutored in politics and ignorant of policy until it hits their paycheck or their lack of a health insurance card in their wallet, to give up on Trump in only six months? They don't see the failures yet, and were blind to the moral outrages from the beginning, blinded by anger at Hillary and her crowd, and blinded by what they took as business success riding to their rescue. It takes time, it just takes time. But just as in the stock market, when the weakness finally asserts itself, it will be unmistakable, even as the entrenched and the stupid hold to their convictions despite their depleted wallets.

To switch the analogy, getting people to change horses is never easy. It will be a trick to combine fierce resistance – necessary to stop the runaway – with gentle persuasion – necessary to get people into the other saddle. Obama could probably manage it, but he's ineligible; Hillary certainly can't, her voice rising with insistent ambition and now with I-told-you-so-how-could-you-reject-me-it-must-be-because-I'm-a-woman. As they say in the market, she's dead money. Obama can't rise again personally to the top, but his role as a kingmaker might just be starting. Meanwhile, we have to await the emergence of a new crop of leaders, those who have quietly doubled and tripled their value with the support of smart money, before the general public is even aware of them. The question will be, when will the old leaders have the grace to leave leadership to new leaders who can lead? Timing is everything.

The trick will be for the new leaders to make sure the current Republican party departs along with the Trumpsters. After all, he just crawled into their own rotting carcass and, lacking a vision of his own, simply adopted their eyes and the goals they had fixed on. He featured himself as a fixer, not a visionary. When it's clear he can't fix, he's dead meat. It will be the traditional Republicans' problem to find a way back from the ideological swamp they have created for themselves.

While resistance is pursued in the Congress and at the grassroots, leadership is likely to spring from the states where positive steps can be taken. It's hard to change an organization from within, easier to create a new alternative. The weaknesses of the small-state weighted Congress are well known; it's hard to get things done there, and the scope is too big for much experimentation. Maybe the progressive states – the Left Coast, Hawaii, Minnesota, the Northeast –can form alliances over issues like climate, minimum wage, retraining, education, health care, or even following Alaska's lead to a guaranteed annual wage. States can do what the feds can't, then threaten to either take over the presidency and Congress, or minimize the feds and just revert to a version of the Articles of Confederation and minimize the federal ability to tax. It's tempting to let the South go its own way and to reconsider the 19th century with expulsion rather than secession, but that's a pipe dream and anyway, there are so many good souls there and some nice vacation spots. Let there be a movement within those recalcitrant states to join the progressives in their policies, like Turkey seeking EU membership. Meet the criteria, dudes.

Change comes slowly, and big change comes only when pushed by crises, and we won't be there for some time, hopefully. Forced secession? A thought when viewing Jeff Sessions, perhaps, or Scott Pruitt, the anointed ignorami. But even if these idiots are with us now, it's just as sure that new leaders will emerge. They will. The question will be, what will the battlefield look like and who will be the contending forces? We can only hope that the current cadres of the Republicans will wither quickly and completely, and that the strong emerging forces will not have to wear too much of the old Democratic uniforms, and that the officer corps has some idea of progress that can whip the troops into shape to work together, without the old officers held over with their bad old habits, and just preserving what is best.

As in The Leopard, things must change in order that they can remain the same. We'll see what we shall see. And we must remember to observe the moral imperative of optimism.

Budd Shenkin

Friday, July 7, 2017

BNS Returns To HMS





There were 10 or 12 of us sitting in a circle on Friday morning, and Judy said, “It's just too bad we have to die, when this is the best part of life.”

I was startled. I said, “What do you mean?”

She said, “We've done all we have to do now.”

Yup, that was it. “That's just what I think!” I said. I was the only other one I had heard say that.

These were some of my closest friends in the Harvard Medical School class of 1967, which now seems both long ago and yesterday. We were lucky to be sitting together here in the lounge of Vanderbilt Hall, our dorm for the first two years, where we descended the 15 steps or so into the dining room, where my classmates had spotted me every morning in September of our second year, calling out, “What happened to your Phillies last night?” during one of MLB's legendary chokes – it had to be the Phillies, didn't it? Here in Vanderbilt is where we became so close. Not Judy and I, necessarily, which was one reason I was so startled. She had declared herself hell-bent on being a “five days a week psycho-analyst” from the very start, which was probably pretty intimidating to me, since I had no idea where I would be headed, and coddled as I had been, barely wanted a job. And she was a Jewish woman, which was just what my mother was, although from New York, while we were Philadelphians – big difference. But here she was, making my point.

HMS hadn't made it easy, then or now. Just to have access to this room to sit with each other, we had had to insist on our class listserve that the primary purpose of the reunion in our eyes wasn't as a donation opportunity, that we didn't necessarily resonate to the administration's declaration that “The World Is Waiting.” TWIS for HMS? Doesn't that really say it all? And the vacuous, fatuous declaration from the staff organizers, “The Best Reunion Ever!” Right, right. And just why would that be?

I had made the point on the listserve that what I really wanted was to sit down and be with my classmates, and that had gotten a lot of resonance. Judy had said, being practical, couldn't we just have a room? Someone else added, hey, you're sitting on a $23 billion endowment, think we could have a room? It took a lot, this was not easy thing, we were only notified at the last minute, but yes, at the end, we had access to a room where we could sit together, here in Vanderbilt.

I felt the same as Judy, all the boxes had been checked. Had a career, took care of people, accomplished some stuff, set up for retirement, raised the kids more or less successfully. Jimmy chimed in from the other side of the circle that he didn't feel that he had done everything. “I took that long trip to South America senior year, and I thought I had to write a report when I returned, but I didn't. But I still think I do, and I haven't done it yet.” Whimsically said, but then, we were all doers, all responsive to expectations, and it's strange to give that up. I remember when basketball and pursuit of women (girls, actually) were what life was all about and school was something to do well, but not for fun. Now here we were and professional progress had taken over first place, and finding fun for fun's sake had to be recovered, but on the positive side, work had become a lot of fun for so many of us. Isn't it too bad, having got this far, that we will have to call it quits at some point that we are closer to now than we were then?

I'm not one to come into events with expectations, although clearly I hoped to “reconnect,” to see where things had turned out, and what we thought now about what had gone on then. I noticed that everyone was now much more confident than before, which shows how tentative we were then. Now, we had done what we had done, and we had measured up more or less, I guess. There wasn't a lot of preening – there was some – but more like a common feeling that we had survived. I saw my old friends, and Larry said it was too bad we didn't live closer. That was nice to hear. John, old friend from undergrad and HMS and next door neighbor in Vanderbilt, who had nominated me for class VP where I had served (social chairman was a better functional description) for three years, mutual warmth after all those years. Doug from Alaska, always introverted, with whom I now could connect. Don from NYC still with his Arkansas lilt, bringing the message to get that LDL down and live into your 90's! Mona whose husband and daughter wrote “Fuck Feelings,” which we later saw featured over at the Coop in Cambridge, what a great bookstore.

Phil has been a big organizer of reunions, which is a surprise since he wasn't particularly a class leader, but somehow he volunteered and feels deeply about HMS. He and others established a scholarship fund “untouched” by Harvard administration. That's great, show's a healthy skepticism, but in the end money is fungible, but I honor what they have done and their feelings behind it, even if I do not share it. At our intimate dining experience at the St. Botolph's Club on Commonwealth Ave. Phil had observed that there were many who seemed not to appreciate HMS the way he did. “How can they not appreciate what Harvard has given us?” he said.

Well, that's an interesting question. I think fewer than half our class came – 10% are dead, but even half the survivors didn't show, I think – which tells you something. One thing is just technique. I've done this kind of thing, and what you need to do is call everyone personally and engage and let everyone know you, as the leader, want them to come. And make the objective to connect, which is what we want to do, to feel wanted. Instead of sending out a fund-raising letter with a little note in the margin that “we are hoping for a 'stretch' donation! And it will be great to catch up.” Figure it out. (I've compared us graduates with money to the pretty girl who wants to be loved for herself – you can continue with this comparison if you want.)

But in fact, there is a lot of resentment. I talked to Ira and George in front of Vanderbilt, and Ira talked about how he had been abused by housestaff (interns and residents, for you non-doctors reading) on the wards of the Brigham. He had made a rational decision at 2 AM not to awaken a patient to get the med student history for next morning rounds, which would have been in addition to the intern and the resident work ups, and when he was empty handed the next morning and explained his concern for the patient's welfare, the resident in charge had vowed to give Ira pure scutwork the entire next week. Ira went to the Dean of Students who had then called the hospital and complained in his behalf. Ira had had contretemps in his medical life thereafter, and wished that HMS had prepared him on how to deal with those who would take advantage.

I had had some similar hazing from housestaff at the Beth Israel. George, a soft-spoken upper midwesterner, related that he had wanted to set some goals for his daughter so she would have some direction, either towards where he suggested or maybe against, but something. So he thought, what about medicine? Then, from depths he didn't know he had, came out the conviction, “No! I don't want her subjected to that abuse!” He hadn't even known it was there, but there it was. And Phil wonders why everyone doesn't see things as he does. And Phil, these are the guys who showed up.

For myself, I didn't know this was going to happen, but somehow at this visit, I buried the hatchet with Harvard. Yes, they didn't tend much to feelings, they didn't help us understand the process we were going through to become doctors – there was some fake it before you make it, I think, in retrospect. And it's a very hard process, to some extent one that I still wrestle with. Doctors get a lot projected onto them, healers, authority, helpers, confidants, other stuff. They could have mentioned it.

But still, here were my classmates, and I appreciated them so much. Not only are these good people, they are my brothers and sisters, because we came in together undifferentiated, and as different as we are now, as much as reunions are exercises in observing the damage that time has wrought so some of us have to reintroduce ourselves to one another to be recognized, as much as we compare our health report cards like Miami Beach ladies on the park bench, still, we came from the same medical womb and here we are years later. So I found most of my resentments melting away, realizing also how much of it was me and not them. I was young.

Doug wrote to me and I hope we can get together when he's in town. I'm going to write personally to several others and tell them how nice it was to see them. I'll have lunch with Carol, who lives probably just a mile or two away. I'll go back for the 55th, God willing. And unexpectedly, I had a good time with my wife in Boston, despite it's being the home of the Celtics.

Rich said years ago that the strength of HMS is in the students. It was startling to hear at the time, and I was amazed to think that it might be true. I couldn't think in such terms while I was still in the minors. But it must be true. What HMS gets is permanent position for the lottery draft picks, and as Dean of the dental school Bruce says, they figure they do well if they don't screw us up. That modesty is quite possibly false, but still, it is engagingly far away from The World is Waiting.

And you know what? I'll give them some money they don't need, just as a token. For my classmates, who it turns out, I probably love.

Budd Shenkin

Tuesday, July 4, 2017

A Liberal's Dilemma


It's always been tough being a liberal on crime and gangs. It's true that these miscreants have had really hard lives in many instances. Being raised in a poor and disorganized family with a history of failure is hard for me to understand fully, and I'd guess it's the same for most of you reading this. The social and educational resources offered to the poor are dreadful, as we all know, and prejudice makes it all the harder in every way.

And in addition to circumstances, there's the problem for many of not having much personal potential. We have some elements of a meritocracy in this country, more in theory than in fact, but it's there. So, what about the 50% who are below the mean in various measures? Those afflicted with poor brains or poor bodies or illnesses? Sure, many are not good in one thing but good in another, that's true. We make a mistake if we are unidimensional. Sure, hard work and persistence will get you a lot, and just reliability gets you a lot. But as Bernie and Elizabeth and Barack and others aver, the deck is stacked. Jared Kushner didn't get to be worth billions because of his innate brilliance, I think we can agree and think that this will become all the more clear as events unfold.

So, what are you going to do if your way is blocked by so many obstacles? Some are gifted with optimism and happiness and relilience and succeed despite the obstacles. But most don't. And pressures can mount, from here and from there. In the end, the rule of law and the arms of the police are necessary. And some of these dudes are really bad, too, let's not bleed our hearts for them. My stepson Brian is a prosecutor in Santa Clara county, and had the same job in San Francisco, working on gangs in both venues, and the evidence he sometimes brings to the court is video taken by the accused of he himself torturing and murdering a victim. Not much ambivalence on display there. If we are weighing influences vs. free will, it's pretty hard to gather up the sympathy when you hear Brian talk about these guys.

Perhaps you wonder where I'm going with this. Amazingly, I'm meandering over to the subject of abject victim of circumstances Donald Trump. We all know the problems that the rich may encounter. No one is immune to illness, and Donald is no doubt a victim of both ADHD and learning disorders (probably reading deficiency, possibly from dyslexia), and it would seem from the vision we have been offered of the prime source of his medical care (Dr. Harold Bornstein) that none of this, plus much else, has been properly dealt with. We can also imagine the circumstances of his upbringing. Having a slumlord for a father probably did not introduce liberal, understanding values to young Donald, and one doubts that his medical deficiencies were sympathetically considered. Plus, he was probably pretty much as much of a prick then as he obviously is now.

At the time he was growing up we understood so much less about it medically. My high school friend Jonny couldn't finish homework until 1 AM, and his neighbor and intimate friend John joked that that was when we didn't even have anything assigned. We viewed it as a deficiency of organization or of self-discipline or something, although we all loved him. It was only in later adulthood that amphetamine medication made him functional, and even now reading puts him to sleep. But, Jonny persisted and is a radiologist. He had something going for him, however: a supportive family. His father was a religious scholar, and his mother one of those warm, Jewish mothers who overflowed with affection for her son. When Jonny appeared on the front page of the Philadelphia Bulletin as a soldier who was refusing to be shipped off to Vietnam, the Bulletin interviewed his mother, who said “he is such a wonderful boy!” And not only did Jonny benefit directly from this family, he passes it on and lives his life the same way he was treated, thoughtfully, warmly, compassionately. He should be taking some amphetamines but I don't think he is. Luckily, those xray films don't put him to sleep the way books do.

Donald, we can imagine, got none of what Jonny did. He got shipped off to military school, and instead of standing up for himself during Vietnam, he got deferred, as did so many who could. But there probably was very little humanism from his family to introject. From the way he bullies, one can imagine he was bullied. His father probably found him wanting. Donald always made sure he had a great looking date at school functions. He certainly learned to compete in sports. That was him, trying to measure up, trying to have a positive self-image from the outside in. That usually doesn't work too well.

So here we are with a President Trump who reveals himself everyday as an awful human being. Let me not count the ways; who can't do it for himself or herself at this point? No videos of torture and murder, but he edges up to it. Not just a horrible President, who has the opposite of grace, the opposite of understanding, who knows little and learns little and who is unlikely to ripen in office. He has already shriveled, a fitting twin for Jeff Sessions. Once you're there, there is no going back.

So, we once again confront the Liberal's Dilemma. Do we understand and excuse, or do we capture and prosecute? It is a testament to their hypocrisy that the Republican Party of today says – excuse! He's new on the job, he means well, etc. Of course, it's a load of horse-diggy. They will say just anything, won't they? What a collection of losers, devoted to Wealth Care. They decry the lazy (and the sick, for that matter) while they defend the Loser In Chief.

But what do we do, we who are more enlightened, who can understand how people can go wrong, and can empathize with their hardships and dilemmas? Do we want to be hypocrites, too?

Well, let me tell you where I come out. Personally, I support Brian's point of view. Whatever the background explanation, whatever the mix of determination vs. freewill, I'm coming out with a judgement. Gang member killers? Gotta lock'em up, no? What other way is there? Try to rehabilitate when inside – tragedy and scandal how that doesn't happen – but condemnation is necessary.

Consistency demands that we judge the afflicted Donald the same way. It's very hard to grow up with the family we intuit that he had, the pressures, and the illnesses that he still seems not to recognize, but in the end, he has to be condemned as a terrible human being, and I would be far from dismayed if, in the end, the judge were to say, “Lock him up.”

Budd Shenkin

Saturday, June 24, 2017

Death of the ACHA? Senatorial Politics


One of the less elevated reasons I started writing this blog was to get it on the record. “Do you remember, this is just what I said, just what I predicted?” How many times had I said that? Predicting is hard, especially about the future, said Yogi. Right. But I flatter myself to think that that's one thing I'm not bad at. And it just so happens that one of my foibles – yes, I have to say, it's a weakness – is the need to be recognized.

“Shenkin's smart!” Ahhhhh, music to my ears. Yes, it's a foible. But hey, I'm not a saint, God knows, and so do a lot of other people.

So, with the “blog of record” self-designation in mind, here's what I think is happening and will happen in the Senate vis-à-vis health care. I think the American Health Care Act – also known as the I Hate Children And Anyone Less Privileged Than I Am Act – is doomed. No way to square that circle. The moderates, such as they are, can't be brought along. Murkowski and Collins can't vote to eliminate funding for Planned Parenthood, the Right won't stand for abortion funding, and the whole thing is a time bomb for the Republicans if it were to be passed with so many becoming worse off, so those interested in power in the future – McConnell especially – don't really want it to pass. The tax-cutting aspects are a problem, but the rich will get something, don't worry about that, and getting something will be better than getting nothing, which was their alternative under the Dems. Also, even if they have not been way out in the open, the hospitals need that Federal money that comes in via Medicaid and subsidized private insurance. Not to mention the insurance companies. Not to mention the academic centers. Not to mention the jobs figures. So, it's a loser.

Given that prospect, imagine that you are Mitch McConnell. What would your objectives be? You would want to use the situation to strengthen your own power. You would want to show the party members that you tried as hard as you could to do it – promise kept. Then, you would want to help out each member of your Senate delegation in a way that made them more indebted to you. How would you do that?

You would make sure that each individual senator knew that you understood his or her individual self-interested situation. Dean Heller in Nevada, in deep trouble for re-election, which he probably will not achieve in any event. He can't lose all the votes he would by voting against the law that gives so much to so many. “Dean, I understand. You're going to have to vote against it. That's OK, I understand.” Think of the undertaker and the Godfather – someday, and that day may never come, I may need a favor, Dean ol' buddy.

To the Gang of Four on the Right: “Fellas, I understand who your voters are, and how they have to see you. Ted, you asshole, do what you have to do. You others, I understand how your voters have to see you. If it comes down to where I need you because it will actually pass, I'll call on you as a group to come in, but otherwise, you can vote against it as a group, if you want to. That includes you, too, Rand. But I'll let you all make your statements, and if we do pass it after all, then you can come in as a group and defend yourselves that way, and explain all you got by hanging tough.”

To the ladies on the middle (can't say Left with these people): “I understand that you have voters, and I understand that your gender might have some feelings about Planned Parenthood and all, and I know you have to do what you have to do. I don't know if the others can go for something that continues with PP – they have a lot of religious voters – and I don't know if they can spend all that money on Medicaid, it's a lot of money, but I'll try to get them to move. But if I can't, I'll protect you so that you are not the ones who alone push it down. We'll make sure that it loses by a lot and not a little, so you won't be primaried. I am hoping, though, that when the tax bill comes up, that you'll be flexible there.”

So, they will all owe Mitch for tending to their own vulnerabilities. And then when it comes to taxes, they will all owe him, and since tax-cutting gives more than it takes away, and since it's not obvious at the time to Joe Schmo that he's getting screwed, McConnell will wind up a winner.

So, my view: ACHA goes down to defeat, the Dems crow, the hard Right grouses, but it all comes out in the wash with filthy lucre and taxes.

You heard it here, with all the forecasting that's fit to print.  Or, I hardly need to mention, this analysis could be all wrong, AHCA could pass, compromises could be made in the end, in which case, of course, McConnell's stock would be higher than ever, with a great feat of legerdemain.

Budd Shenkin