Tuesday, March 17, 2015

Anthony Doerr responds

On the advice of my friend Bob, who said that he thought the author would like to read my reflections on his book, I sent my last post on to Simon and Schuster to forward to Anthony Doerr.  And here is what he wrote back:

Dear Budd Shenkin,

Thanks much for spending some hours with one of my books and for your gracious and lovely blog post. I’m so grateful that you enjoyed the book. And your post spurred me to revisit the parable of the blind men and the elephant, too. 

Wishing you a lovely and bright springtime,
Anthony Doerr

I was so pleased to get this!  Isn't that nice?  He seems to be a nice man, and actually, that's what you would expect from All The Light You Cannot See.  When we were discussing the book at our book club last night, I realized how much caring for one another there is in the book.  Everyone cares for Marie-Laure, and you the reader are grateful for each one.  Werner cares for his classmate Frederick.  Werner regrets it when he can't care for his sister Jutta, but he thinks about it.  It's the villains who don't care for anyone, and who don't have anyone to care for them.

I guess I'm still thinking about the book.  A good sign.

budd shenkin

Sunday, March 15, 2015

All The Light You Cannot See

I have always been fearful of being blind. I thought, what would I do if I went blind? I might kill myself. It's so important that I haven't even wanted to think about being blind, for fear of bringing it on. Just as Natalie Wood, a Russian – that irrational people – drowned when that was her biggest fear. Just as I for years bought more expensive PPO rather than HMO insurance because I explained, using an example, what if I had a brain tumor, I would sure want to go to the best place for it, wouldn't I? So sure enough what was it I got, a pituitary tumor. Close enough. And I was going blind with it before the operation. So blindness, not that I'm superstitious, I'm not, but still, just don't think about it.

So I didn't want to read “All The Light We Cannot See,” by Anthony Doerr, even though Sara my stepdaughter gave it to me for Christmas and Sara's choice of books is always, always excellent; and even though my friend Larry pushed it as a read for our book club. I just didn't want to read it. I didn't want to read about some blind girl and what she goes through. But when the book club chose it, and I even found myself putting my hand in the air voting for it somewhat unaccountably, I had to.

I loved it. I cried at the end, even though it's not a tragic ending, it's just time going on and people living in it. OK, the guy's a great writer. He can write sentences, he can set a scene, he used a modern form with short chapters following two main stories simultaneously, and a third smaller story coming in a bit later, and the stories shifting from pre-WWII to 1944 and 1945, back and forth, in a way that really works to build affection for the characters and tension in the story and the three strands all intersect at the climax, as you know they will, so I'm not giving anything away. And as I say, I guess I cried at the end, tears came to my eyes and even though I'm allergic and it's flower season and all my bulbs are coming out in the front yard and the window was open and it was near dawn as I finished it, I think it was the story and not my allergies.

For me, this book was an eye opener, especially with my fear and dread. (Don't think about it.) Marie-Laure (love the name, especially since Laure is the name of the female principal in Spiral – see Netflix) loses her sight to congenital cataracts at the age of 5 or so in pre-war Paris. Her mother died in childbirth and her father is a saintly dad as he raises her and loves her. He cares for her, he is tender, he makes wooden scale models of the neighborhood so she can feel them and orient herself for moving around, and he is a genius in constructing the wooden models with secret ways to access the insides that sometimes contain presents for her. She feels her way by touching his pants, she feels and hears – I know we've heard this about blind people, how the brain expands in the areas that function to compensate for the loss of sight, but Doerr brings us to exactly how it feels. Later on, when she is at St. Malo – which by coincidence Ann and I visited just last year, so I know it, even Place Chateaubriand http://www.trekearth.com/gallery/Europe/France/West/Bretagne/Saint-Malo/photo1392483.htm – she can tell all the snails and other molluscs by feel; she is a natural biologist taught by her father and colleague at the museum where he works. People are so kind to her. Her world is not like seeing, but it's her world and it's a tender, exquisite world all by itself.

The parallel story is about a short German boy with white hair named Werner, a little older than Marie-Laure, who lives in an orphanage near Essen, who has a mechanical ability. He makes a radio and he and his precious little sister Jutta listen to it and hear a Frenchman broadcasting stories about science and physics in a warm and cuddly voice. Because of his emergent ability Werner is chosen to escape the mines and become brutally trained in a Hitler youth school, where he befriends a gentle soul, Frederick, who identifies birds by the songs he hears, not needing to see them. Werner helps invent the technology that triangulates radio signals to find hidden broadcasters. So, I realized, Werner is like Marie-Laure, because he uses radio with his ears and not the eyes. When his hearing is translated into sight, his friend the giant soldier strides into small, primitive cottages that are broadcasting and kills the partisans as they transmit.

As I was reading and realized this, it hit me – what I am doing is a blind activity, too! I'm reading and making up pictures in my mind. Reading is like a blind activity, so I'm part of it, in it with them, doing a similar thing.

And then I thought even more – “Keep thinking, Butch, that's what you're good at!” – we are all so often looking (note, “looking,” maybe it would be better to say “listening for the future”) but we really can't see it. We imagine what it might be, we seek indicators to project what it might be, but we are really essentially blind to the future. Sometimes if somebody thinks he has it, he'll say: “I can see it clear as day!” Maybe. It sure is great when you can.

And then, Doerr is constantly referring to what is happening in nature as events unfold. St. Malo is about to be besieged, the populace is being herded into areas, airplanes are dropping bomb loads, food and water are missing – and what is happening in nature? The birds are doing what they always do, chirping, finding food here and there whatever it is they eat, I think Doerr knows what that food is but I don't. The snails are doing what they always do, creeping and filtering the calcium from the water to build up their shells. They are blind to what is going on around them with the people and the larger landscape, just as the people are blind to what is happening with the birds and the snails.

Then there is the long term working of nature, the evolving crustaceans and molluscs that Marie-Laure orders in her bedroom, so she can feel them as they have evolved, see the long term trends and changes maybe you could say. No one planned it but it happened and afterwards we see the results, but never before. We can see the past, which we can't affect, but we only intuit the future, we only hear it coming but we don't know exactly what it is.

Marie-Laure's favorite book is Jules Verne's 20,000 Leagues Under The Sea. She learns to read it in Braille, and later she reads it on the radio. Captain Nemo explores, but he often can't see much. He is under icecaps and he is picked up by a giant squid, which he can't actually see. The sea is dark and inky, and he and the sub are tossed about, hoping for the safety of chance. Listening to Marie-Laure read it on the radio, Werner is just like her, because neither of them can actually see what it is, they are picturing in their minds.

I think it's just coincidence, but just in the last few months before reading All the Light, I have been thinking more and more about the parable of the blind men and the elephant. http://www.buddhisma2z.com/content.php?id=471. We really see so little of what there is in life, we understand so little. It is best to be humble and listen, but it is also important to try to understand, to try to put things together, and to try things even though you know that your vision is limited and many of the things you try to do will fail.

What a book!

Wednesday, March 11, 2015


On our SOAPM pediatrics listserve we have had a conversation about treating strep throat. The options are: (1) take oral antibiotics once or twice a day for seven or ten days, or (2) get one shot of penicillin at the time of the visit. Factors include the fact that a shot hurts (briefly); and that it is hard to fulfill the oral medicine instructions for a week or more even if it is yourself, let alone a kid, so that “lack of compliance” becomes an issue with oral medication.
Myself, I've always been a shot guy. Over and out, I figure.
But many of the doctors wrote that they hesitate to give the shot because they themselves remember the pain when they were kids. For instance, my friend Iris Snider from Tennessee writes: “Kim, like you I had my share of Bicillin shots as a child and am loathe to give them. I average about one every 10 years and apologize to the 'victim' every time I do.”
Here's my response:
When I was probably about 6 or so - I was born in 1941 - it was summer and we were at the New Jersey shore, in Beach Haven.  Somehow I got an infection in my foot.  It was bad enough that I had to go back to Philadelphia and was hospitalized, probably at Graduate Hospital.  Penicillin wasn't that old a drug and we were lucky to have it.  At that time there was probably only crystalline penicillin.  I don't know if it was every four or every six hours that the nurse came into the room with a big hypodermic needle and I cried at the prospect and my mother helped to hold me down.
Then after a while my mother reasoned with me.  She said, “Look, it's going to be done, so why don't you stop resisting and just accept it and make the best of it, and after all it is fixing you all up,” or who knows what words she used. 
The next time the nurse came into the room I smiled and turned over and offered my cute little butt to her ministrations.  She said, “Well, what got into him?”
And you guys are complaining about a one time shot, with pain-killer as one of the components, when the kid can walk out of the office and not think about it again?
You should have been in Philadelphia right after the war and seen a little kid with a foot infection in the hospital bed and offered him that choice!
Budd Shenkin

Monday, March 2, 2015

Vaccines, Anti-Vaxers, SOAPM, and Jimmy Kimmel

Pediatricians have been hot! Ever since measles spread out from Disneyland, what we have been dealing with internally in pediatricianland, how to deal with the anti-vaxers, has gone mainstream.
For me the heart of pediatricianland is SOAPM, the Section on Administration and Practice Management of the American Academy of Pediatrics. There are over 1,100 of us in this section, and on the SOAPM listserve 50 messages a day is a slow day. If you are lonely and have little to do, joining SOAPM can fill up your day real fast. And truthfully, SOAPM has become a real home for me, and my admiration for SOAPM denizens fills my heart. It makes me so pleased and proud to be a pediatrician. Practical people, assertive people, inventive people, imaginative people, people with great hearts and minds and values, people who are not ashamed to say, “No margin, no mission!” And then they go out and do the right thing.
So when measles got hot, SOAPM got hotter. Some of our energy has been going into how do we convince anti-vaxers to vaccinate? Some energy into, what does our American Academy of Pediatrics do with the rogue pediatricians who capitalize on the anti-vax movement to sell books and get publicity? Shouldn't they be drummed out of the AAP and lose their imprimatur as Fellows of the AAP? Some of our energy has gone into how the AAP should respond publicly, especially after they issued a somewhat tedious statement once again reaffirming the value of vaccination with zero pizzazz. Some of our energy has gone into trying to get the AAP to revise its statement that practices should not dismiss patients who delay or deny vaccination, but should work with them.
Truth to tell, my practice was always counted among those who accepted anti-vaxers and worked with them. But now, if I ran the zoo, I'd change that. For one thing, the public tide has turned and there is value in putting up a common front. For another, there is now evidence that shutting out antivaxers convinces more patients to vaccinate than “working with them.” But of course I know longer run the Bayside zoo – thank goodness!
But then, while all the sturm und drang of SOAPM dialogue was proceeding, up came a message on the Listserve from James Weidman of Los Angeles – “Watch the Jimmy Kimmel show,” he said. And then came this clip:
This clip made me so, so proud to be a pediatrician and a SOAPMite.
OK, the AAP was too reserved and stodgy. But, is this a great country, or what? In liberal democracies there is a multiplicity of channels and freedom of expression. Enter popular media! Enter emotion, enter sarcasm, enter dirty words! Enter great intelligence and communication and presentation skills, and enter great directorial skills that enabled these real life pediatricians to be such great performers! To me, these pediatricians perfectly bridged the profession's rectitude with being able to relate as lovable human beings, which to my mind is the essence of being a pediatrician.
I am just so proud!
Sometimes, the best politics is great entertainment.

Budd Shenkin

Sunday, February 22, 2015

Israel, Arabs, and Postulates for Living

Postulate one: you learn in life that generally you can only control what you yourself do. Others will generally do what is in their own interest, except your parents, if you are lucky, and except your spouse, if you are lucky, and sometimes other members of your family, or sometimes someone else, but you can't count on it. It's a blessing when someone understands you and helps you, something to be relished.

Postulate two: it doesn't help much to blame others and to hold a grudge. I'm talking about utility, not justice, and not even truth. If things go bad, you do best to look at your own actions and make them better next time. You can acknowledge what somebody else did wrong, and how somebody else is a jerk, but aside from choosing who you associate with next time, blaming somebody else doesn't have that much utility, except maybe legally.

Postulate three: it's a good thing generally to do “the right thing” without expecting either appreciation or reciprocity. Don't go crazy about it, but just do the right thing, even if the other one is a jerk (most people are not jerks all the time, although I've heard that some are, mostly concentrated in the financial industry.) You may get appreciation, you may get reciprocity, or you might get resentment. Still, I think it does you the most good to do the right thing. Just don't go overboard.

Do these postulates apply in political affairs? Especially, do they apply in international affairs, where I believe there really is a clash of civilizations? Clearly, turning the other cheek to Mr. Putin is not the right thing to do. Bullies must be stood up to, not collapsed to.

But let's not talk about Russia, let's talk about Israel. The Israelis are much afflicted in their neighborhood, where school children in neighboring Muslim countries are taught to hate Israelis and Jews. Being sweet to Hamas or Hezbollah isn't likely to help much. Even being nice to the Palestinian Authority brings a mixed bag; the PA has to answer to its people, and there enough hard-liners to make it very difficult to make progress.

But thinking a little more short term actions and long term results, 20% of Israel's population is non-Jewish, mostly Muslim, but also Christians and the Druze. This population is generally discriminated against in many ways. But in fact, they offer a major opportunity for Israel to do the right thing.

So, here's the proposal: If Israel took this population as a gift, as an opportunity to do the right thing, it is possible that they could really make some headway. What if they preferentially delivered excellent educational opportunities to them? What if they practiced affirmative action for employment? What if they went out of their way to make this population successful?

OK, it would be hard to do. But imagine what might happen. First of all, would they be appreciative or resentful in the short run? Or suspicious? Probably appreciative and suspicious, but who knows – I've never even been to Israel. But I can't imagine that this population wouldn't take advantage of a smoother road to become educated.

Then what might happen? They might become a very economically successful part of Israel. They might develop their own institutions, but they would probably just integrate. I can't imagine the Jewish businesses not incorporating such talent. In time, these non-Jews might become some of the most appreciative and patriotic citizens of Israel of all.

Then, what happens in the rest of the Arab world? Well, they might declare jihad against these turncoats, some of them. But mostly there would be envy and maybe admiration, and maybe even competition. If there were resentment and denial, it would be rebutted by families and relatives who would know the truth.

The truth would out. The eighth century Caliphate ideal would be replaced by the twenty-first century modern ideal. The misled Middle Eastern Muslim masses would be slow to come around, but thought leaders with some sophistication would privately and then publicly point to Israel as a beacon for Arab advancement elsewhere. There would actually be a way out of the tunnel.

Call me a fabulist. Call me na├»ve. Call me uninstructed. But, as they say in the movie review part of Robert Townsend's Hollywood Shuffle, “It could happen.”

Or maybe nothing would happen. The Israeli right wing would waylay it; the Arab world would become even more antagonized by the attempted seduction; the most respected law of social affairs would rear its head, the Law of Unintended Consequences. But so what. At least the good people of Israel would have done the right thing, and that is reward enough on this earth.

Budd Shenkin

Saturday, January 31, 2015

Accountable Care Organizations, Hospitals, Primary Care, and Ptolemy vs. Copernicus

In a very interesting post, Paul Levy wonders if Accountable Care Organizations will really be the panacea for cost containment and more rational and organized medical care that some people are hoping for:

His skepticism is well founded, I think. The basic idea of ACOs came from the Dartmouth researchers, who started in the 1970's studying rural New England medical neighborhoods located around a single hospital, and found that there were small area variations in the customs of treatment. Some areas had lots more tonsillectomies than other areas, for instance, with no difference in the population. They posited that having lots of ENT doctors in an area led to more tonsillectomies, and found other such correlations as well. This was great research!

From there the concept has expanded, and every area of the country is now viewed as having the same organization as rural New England, centered around a hospital. The idea of ACOs is to take this putative neighborhood – and if there is no such neighborhood, to try to make it into one – and organize it differently, so that if a more formally organized group of doctors and hospitals can rationalize the care and make it less expensive, they can save the country money and make a little bit more themselves, by being well-coordinated and abstemious in their care.

This insight is that of corporations. If one brings all participants in a system under one roof, the processes can be rationalized, and the increased profits shared among the participants. The opposite theory is that of a market, where all elements are independent and competitive horizontally with one another, leading to more efficiencies not by corporate regulation, but by decentralized invention. Sometimes one theory works, sometimes the other theory works. The main variable in deciding which one is better is transaction costs: if they are high, it's better to go with a corporation; if they are low, a market is better.

Personally, I like a competitive market. I think a corporation should always be the second choice, because I think people will do what is comfortable for them personally unless they are forced to compete. But I have to admit that sometimes corporations can be great. Which should it be for the medical neighborhood?

The ACO concept is corporate, and indeed, the FTC needs to give ACO's a pass on anti-competitive practices for them to be established. My concern is that the way hospitals and specialists (who will most often be in charge of the ACO's) view the world is Ptolemaic. They see hospitals and tertiary centers and the specialists – the high priced elements of the system – as the center. Is this as it should be? Should these elements who drive the high cost of care, the high price of care, be at the center of power? 
Let us recall again the parable of the blind men and the elephant, each describing the whole as being the part that they are feeling. To hospitals and specialists, what they do is the core of medicine. The way they do it is the core of medicine. Put hospitals in charge and we will find ever more administrators populating the system, producing more of the same cost escalation, just as higher education costs are fueled by more and more university administrators. Put specialists in charge, and they will be driving primary care by their own lights, dishing out more and more of the current tasks of specialty clinics for the primaries to handle. The cost of care might well be reduced, and certainly the cost of specialty clinics will be reduced, and they will thus be paid more. But, they haven't thought things through. If the specialists dump more of their work on the primary care practices, what primary care tasks will these specialty tasks displace?

Little understood and valued by the hospital hubs, primary care has its own agenda. Primary care is the place where patients and doctors interact most constantly and most intimately, over a long term and many different issues great and small. Primary care is where prevention and health promotion take place. But here is where the blind men and elephant come in. Do the hospital and specialty hubs realize and value this? Not really. They call it “hand holding.” Well, yes, we do hold hands at times. That's valuable; that's important; that's human. That's what doctors are supposed to do.

But the medical care system does not value primary care services highly, literally. There is a system called RBRVS, that puts a value on everything medical. Unfortunately, specialists run the RBRVS system, and mirabile dictu, it turns out that specialist procedures are valued more highly than primary care. So specialists earn more. And since money measures all, it turns out that specialists are more valuable than primaries. It must be, then, since they are worth more, that specialists are smarter, and therefore they are worth more. And that primary care isn't worth very much, so why not have them do more specialty care?

But that's not all there is to it. People are concerned that primary care will not do their job properly under ACO's – not because they will be doing specialty work, but because the payment will be changed from fee for service to capitation. So, how do they defend against primary care dereliction of duty? Measure primary care performance! 
Well, one might think that this would indeed ensure that good primary care work was being done. And it would – if the “quality measures” worked. But they don't. They suck. People have tried, and there are many, many measures – too many, actually, and different ones employed by different measuring agencies so that there is now a movement to consolidate and have all agencies measure the same thing. But that really doesn't matter, because they only measure what is measurable, and most of the most important elements of primary care are not measurable. It is a common problem: "Not everything that counts can be counted, and not everything that can be counted counts."  (William Bruce Cameron.) 
Here's a good example: one of the most important functions of primary care is making a good diagnosis. This is completely unmeasured, yet what could be more important? I had a young mother in my office on Tuesday whose own mother just died last year at the age of 43. The story was that she seemed to have thyroid deficiency that was untreatable, no matter how many pills she took. A new doctor took over and just followed the old doctor's regimen and the patient still was no better. Then the diagnosis finally declared itself: disseminated ovarian cancer. The young mother in my office is completely devastated by the loss of her mother, and the incompetence of the care. She said she was going on a doctor strike, not seeing anyone herself, and seeing one for her son only reluctantly. She was relieved to meet me as someone who practiced in a practice with a strong reputation,and as someone whom she could obviously trust, because I was a mensch, I listened and understood and was empathetic and talked to her in the right way -- I've been at this a long time and I have learned. 
How would quality of care assessment work in the case of her mother? Not at all – they don't do diagnosis. How would it work in assessing my work in reassuring my patient (mothers are actually our patients, as you know)? Not at all, or maybe very indirectly with some general patient opinion surveys, which are in the main completely unreliable and structured for coding of answers so that promptness is equal to “listened to me,” and empathy doesn't appear. So, are we really going to count on “quality measurement” to ensure that primary care thrives in ACO's?

I'm not saying that ACOs can't work, but if they are to work, there has to be a Copernican revolution. Primary care needs to have its own center of power within the new organization. In addition, primary care needs to find its roots and find its leadership based on those roots. Its roots are in the personal relationship of trust and intimacy between doctor and patient, and in healthful guidance and advocacy from the doctor to the patient. This is just not easily measurable at present. One can't measure the end results of this process well, it's too hard to do so. If there is to be measurement, and I guess there should be, then it needs to be a process measurement. What values permeate the practices? What procedures are undertaken to ensure that positive reinforcement of these values takes place? What leadership is in place? There are lots of objective measures that can hit on this, but no one is using them now, but they should. And, we need the primary care leaders within the organizations to give the stories, give the anecdotes, promote the values, and get the rest of the system to appreciate what primary care does. 
And then finally, we need the primary care leaders to get more money for their doctors, more money for their practices, and then attract the medical students and residents to primary care, so there can be someone there to do the jobs they are promoting as so important. That's what has to happen if ACO's are going to do some significant good. The odds on this happening. Low, sorry to say. But stranger things have happened. Copernicus did emerge, and there was a revolution in his wake.

Budd Shenkin

Friday, January 16, 2015

Selma - Not One for the Ages

We saw “Selma” last night. It is a powerful movie. Young as we are as a country, our mythical events are mounting steadily: Roanoke; the Pilgrims; the American Revolution; the Founding Fathers; Lewis and Clark; Lincoln and the Civil War; FDR and the Great Depression; the assassination of JFK; the Civil Rights Movement; a man on the moon. A short history compared to other countries, but with a sense of mythical mission and many enshrined moments.

I don't know if we have more myths than other countries – probably not, I probably just know them more because I'm an American. We are certainly a self-conscious nation, and it seems a nation given to drama. But in contrast to other nations, we have a command of media that no other nation has in the present day, and certainly far beyond any nation in the past.

Think about the ancient Greeks, just for contrast. They were a people filled with mythology, not just the gods, but the historical Trojan War, and the historical House of Atrius. In that time of low technology, how amazing it is that they preserved their myths for all time. For the Trojan War, they preserved it by oral tradition – oral tradition! They made it into a coherent story, and then they had to remember it, so they used repetitive phrases (“rosy colored dawn”) and most importantly, rhyme – rhyme is beautiful, but it is most importantly an aid to memory. That was their technology in the Mycenaean civilization. The oral tradition preserved the Trojan War epics until papyrus emerged in the classical ancient Greek world half a millennium later, and miraculously, the epics were thus preserved in written form.

At the same time, classical Greece had performance art to present and preserve their myths, not only of the Trojan War, but of the House of Atrius. Luckily for us, although the actual performances of their plays were themselves evanescent, the scripts of perhaps 1% of their plays were preserved on papyrus. It was a small sample, but it is enough for us to appreciate their dramatic sense of themselves.

Then, with the technology of writing on papyrus at hand, the classical Greek world invented history with Herodotus and Thucydides. Without the need for gods, drama, and rhyme, facts as the writer knew them could be approached directly, and causes postulated and probed. The search for facts wasn't then what it is now, but at least direct experience could be accurately transcribed.

Contrast the Mycenaeans and the Greeks to us. How easy it is to collect facts; how easy it is to write about what people have done with a fair degree of accuracy; and how incomparably powerful it is to convey visions with the most powerful instrument for conveying someone's vision that has ever been invented, the movies. A play is one thing, it allows one to imagine that the abstraction one sees on the stage is truth. But a movie is something far more powerful -- it shuts you in a room, dampens any other sensory distractions, focuses your attention on colors and giant images that are as clear as can be, and envelopes you in surrounding sound. There is nothing like a movie. Movies are the most persuasive, impactful, and indelible of any media ever invented. Movies are not only powerful, they are so easily accessible; more people see movies than read books or see plays by orders of magnitude.

So, where does that leave us with the movie Selma. It is, as I said, a very powerful movie. It is professionally done, with some excellent performances, and I think especially excellent camera work. It is impactful. It is in service of one of our most important myths, the Civil Rights movement, and one of our most important heroes, Martin Luther King. The problem with Selma, however, is that it contains a horrible lie. It is factual with the African-American protagonists, but it is terribly wrong in the way it treats Lyndon Johnson. It casts LBJ as an adversary to MLK, when in fact he was an ally. The story of the Voting Rights Act in fact has two heroes, and the film proffers only one.

Now, if you are trying to remember the Trojan War and you have only an oral tradition to use, you might well have to simplify, you might have to create a drama that centers on a central truth, and to invent and distort other truths so that the epic can be remembered and retold. It's something you might have to do. Your mission might not be history, but eternal truths, and to get there you might distort facts, but everyone knows who listens that this is the case.

If you are a historian of the Peloponnesian War, many facts might not be available to you, and you might have to tell only the part that you know to be factual. You might seek to highlight some eternal truths, but you do it within the facts as you know them.

Here in modern day America, we have different conditions from the Greeks. Both traditions continue, drama and history. We have new technologies that make drama more compelling (at least technologically), and we can ascertain historical facts as never before. We also have some of the same limitations – a movie like Selma has to make its money back, and so it needs to be dramatic. It also wants to make its essential points of bravery, glory, personal foibles, internal differences of opinion, etc.

But how far do you have to go in this mission? Do you have to lie? Does drama inevitably have to distort reality? Does drama have to disserve history? And if so, how much? What does “artistic license” entitle you to? (And, how much does artistic license act as camouflage for poor artistic ability?)

I can see the need sometimes to collapse two characters into one memorable character, if they are not the main roles. Maybe it's even OK to say Connecticut was against the Emancipation Proclamation when it wasn't (I actually don't think it's OK, but maybe I'm wrong). I definitely don't think it should be permissible to say that torture evokes information to locate Osama bin Laden when it didn't, that's really a lie that's too important to justify.

The issue is this: in the modern world, drama morphs into history. So many more people see a movie than read the books, and a movie is by nature so powerful, that the movie's “facts” are what people remember as truth. So you can say you have a drama, but you really need to act with the constraint of being reasonably close to history. What is “reasonable” is the point of contention.

To my mind, the lies of Selma are so profound as to be infuriating. They shouldn't have done this. What they have done is to sully the reputation of a great if terribly flawed man, Lyndon Johnson, when what he deserves is the exact opposite.

Selma doesn't shade the truth – Selma lies. Selma depicts Johnson telling Martin Luther King, “Not now. Wait.” This is simply untruthful. We have documentary evidence, we have recordings(!) of their conversations where LBJ tells MLK to find the best examples he can of the injustices laid on the African-Americans and publicize them, and the people will see, “That's not fair!” And then Johnson can deliver. That's what LBJ says.

We have the truth from Robert Caro's LBJ books – the truth is more than available. LBJ rose from poverty and the disgrace and financial decline of his father, from his own deficient education, to become adopted by the Southern masters of the Congress, and to lead and command the Congress as no one ever had. He worked as hard and as skillfully as anyone has ever worked in politics, and when he got to the top, he double-crossed his mentors. While they supported continuing the status quo and segregation, the LBJ of his boyhood turned on them, skillfully and with some compassion, but he turned on them for what he knew was right. Having risen by dint of their patronage, he now led the nation not toward their way, but toward the way of Martin Luther King. He threatened and cajoled and got the most significant civil rights legislation passed in over 100 years – and anti-poverty legislation as well.

But what do we see in Selma? We see a limited, self-interested man in cahoots with J. Edgar Hoover, of all people, which is just not true. In fact, Hoover was an insubordinate opponent to be outwitted and ultimately overpowered, with great skill and even bravery from LBJ.  We don't see the conjunction of two stars, the preternatural leadership genius of the young MLK who has known only one way, and the older genius LBJ who has led the more tortured and circuitous way to greatness. I'm sure it's harder to make a drama with two stars coming together, rather than one star with an adversary. Maybe the writers of Selma weren't up to it. But the way it is, it's a distortion, it's a desecration of LBJ, and it's a desecration of the truth. Even if our view of LBJ doesn't have the policy implications of Zero Dark Thirty's utility of torture distortions, it's still important.

It's true that the Civil Rights movement deserves to live in the mythology of the nation. The Black heroes of Selma deserve to live in history and myth. But because of taking the easy way out and gratuitously desecrating a white man who was a true hero of civil rights, this film is truly, truly misbegotten.

The Greeks would have done it better.

Budd Shenkin