Saturday, March 16, 2024

Israel, Anti-Semitism, And Our Dilemma

 

A friend of mine sent me this disturbing, unbalanced expression of discontent by Joel Kotkin from The Claremont Institute. > https://americanmind.org/salvo/golden-land/. Imagine, unbalanced right-wing distraught expression of alarm from the Claremont Institute, who'd a thunk it.

Before the war, last February, in an acclaimed blog post, I set out what I thought US policy should be toward the increasingly illiberal leaning Israel. I said basically that much of what had drawn us toward Israel for decades, before the Likud-Netanyahu-extreme religious right descent, had disappeared. So we had to start regarding Israel as an ally of convenience more than an ally of conviction.

http://buddshenkin.blogspot.com/2023/02/on-israel-and-american-policy-toward.html.

Now, of course, our dilemma is even more acute. If Israel makes it difficult to support them, Hamas of course makes support of them totally impossible – except they are getting it. But I'm getting ahead of myself.

In reading the Claremont article, which bemoans what he identifies as rising anti-Semitism and insufficient public opposition to anti-Semitism, I find some agreement. I, too, am appalled at the support given to the lefty teachings.  I am appalled at the pro-Hamas virulence, and the lack of arrests and expulsions when they cross the line.  Lefty faculties are appalling.

But, once again, there is the problem of anti-Israel vs. anti-Semitism.  They are not the same.  I think much of what Israel has done, has been, and continues to be appalling, and it has spawned ever more Israel isolation in world politics.  i find too many Jewish organizations saying, either you're pro-Israel totally, or you're anti-Semitic.  Israel would have a lot more supporters if their politics and West Bank actions and declarations of intent to wipe out all Palestinians were not so dreadful.  Netanyahu and colleagues have squandered the ethical high ground that Jews have occupied previously.  There is a reason so many American Jews, and others who would be friendly, hesitate in their support of Israel.  Most people feel, I think, that Israel has a right and a necessity to exist, but not a right to oppress.  Not to whitewash the dreck of Palestinian and other Arab and Iranian organizations, and not to whitewash the ignorant anti-Semitism of the unwashed left here and abroad.  And certainly not to whitewash all the anti-Semitism exported from Arab countries.  I wish they would all return to where they came from and see how they like living under Assad and other friendly murderers.

Likud and the Israeli right wingnuts have put Jews worldwide in an impossible position. How do you support liberal values and the existence and need for safety for Israel, when the state of Israel's policies are so difficult to support?  It's so difficult to say one hates the government and its policies and that some of its leaders belong in the Hague, but we need to give all our support to Israel and let them do and say whatever they want, when so much of what they want is heinous.  We just have to wait out the crisis, I guess, and hope Netanyahu goes to jail soon, while strongly resisting and calling out anti-Semitism.  Jews need to be judicious -- strong but reasonable, and not exerting wealth and power tools on the universities so prominently, which fuels paranoia and anti-Semitism. Being judicious in these circumstances is really hard.   

One of my friends read the piece and was disturbed. He is dissatisfied, as Kotkin is, with the Democrats – Progressives support for Hamas is really appalling and surprisingly widespread, but he is dissatisfied with the rest of the Democrats as well. He wishes for a moderate third party messiah. I had to say, friend, ain't gonna happen, can't happen, all third parties are destructive -- although I think Kennedy could drain some votes from Trump.  I'm hoping that the security community drops its non-partisan stance and says, we are partisan for democracy and the continuation of American leadership of the free world, and therefore, even though we are predominantly Republican privately, we are dropping our reticence and urging everyone to vote for Biden, or else we as a country are doomed.  Maybe that would help.  The Democratic party, which is not a stronghold of anti-Semitism at all, and which has good policies basically in so many areas, although there are certainly anti- Semites in their Left wing -- is the only hope.  And anyone who thinks that Biden hasn't given enough support to Israel - at great political cost to himself - is mistaken. He is giving more than they have a right to expect.

Anyway. As I used to hear on CBS when it was reputable, That's the way it is.

Budd Shenkin

Monday, February 12, 2024

Gerontology: The Profession vs. The Job

 

Caring For Older Patients Is Not American Medicine's Priority

There is a prominent paradox in American medicine: we have an ever increasing elderly population, both in numbers of patients and the age of patients, but our capacity to treat these patients is not increasing proportionately. In other words, we are falling short now and if the trend continues, we will be doing worse and worse as time goes on. This is a well known problem, and even if it does not seem to provoke much action, it does provoke words. That's hopeful, in a way, because words are often a prelude to action, although when we look at the problem of global warming, we realize that words are often less effective than the appearance of the crisis in full-blown form. Humans tend to react to crises rather than plan for them, unfortunately.

So that's where we stand, we are talking about this crisis of an increasing population of the elderly.

In August of last year, two articles on older patients appeared in the medical literature, one in JAMA and the other in the NEJM, that illustrate our impasse. What do you do when there is little progress? The JAMA article is one of frustration. The author asserts that the field of geriatrics is so intrinsically interesting and important, yet the number of geriatricians is dropping, and he can't imagine what more can be done to attract young medical professionals. The NEJM article doesn't even mention the crisis of manpower, but it sets out in extensive and thoughtful detail what the authors think ideal arrangements would be to provide medical care for elderly dementia patients.

Here's the JAMA article.

The Paradoxical Decline of Geriatric Medicine as a Profession

Jerry H. Gurwitz, MD

From The Journal of the American Medical Association (JAMA), August 4, 2023 (https://jamanetwork.com/journals/jama/fullarticle/2808221)

The author, an academic geriatrician, bemoans the chasm between the need for geriatricians for an aging population, and the deficient supply of these specialists, that is withering even further.

The situation mystifies him. After all, the work itself is so interesting! Old people can have so many diseases and conditions simultaneously, many of them cannot be cured, the surrounding families trying to help in care can be stretched and exhausted, and putting together interdisciplinary teams for care can be so energizing! Well, Jerry, you say it's “interesting,” I'll give you “challenging.”

Moreover, he says, the money for research in geriatrics is increasing rather than decreasing, even some foundations are pitching in to support the teaching of geriatrics.

Yes, he agrees, the money is not great, and in fact, if you take the time to become a geriatrics specialist after your internal medicine training, paradoxically, you will earn even less than you would if you just stayed an internist! But then, pediatrics pays poorly, too, and pediatrics remains a fairly popular specialty, he says. (He could have looked further and realized that adolescent medicine, which like the geriatrics situation, takes extra time to qualify for, then enables you to make less money than if you had simply started practicing pediatrics, and adolescent medicine also has trouble filling all its spots – he didn't look quite far enough for a correlative situation.)

It must be the culture, he says, where old people are looked on with some disgust, agreeing with Louise Aronson and her great book, Eldercare. And it must be the graduate education councils that don't require medical students and residents to be exposed to geriatrics. (Adolescent medicine wages this same fight, by the way.) And it must be the health care organizations that take the extra money that is paid for treating the elderly (if you code properly, which they do, because it means more money,) but they keep the money for their organizations and their goals and profit, and they don't plow the money back into the organization by hiring geriatricians and serving the elderly better.

Jerry has no answer, no path forward. He is reduced to saying, the problems with an aging population will only mount, and people – you'll be sorry you have been making these anti-geriatrician choices!

Well, he's right about the need, and he's right about societal prejudice (I have it myself – I chose to be a pediatrician, partly because I thought of the dear kids and hopeful families and the futures they had before them, which old people don't.) And tastes vary – some people love working with old people and some don't, and it will ever be so. Like for me – give me the kids, every time.

But the main problem that Gurwitz isn't dealing with is the difference between a profession and a job. There isn't a single reference in his short paper to what it's like to have the job of being a geriatrician. Is it a good job? Are geriatric practices well resourced? Does a geriatrician feel like the captain of a team who can call on A and B and C to deal with the problems of his or her patients? Can the geriatrician identify a problem of insufficient assistance in the home, and assign a member of the team to solve that problem expeditiously, and then to report back, problem solved? Or is it always a struggle, always slogging through sand, begging for this or that agency to come through, looking for financing, etc. Are home supports easily available, with all the durable medical equipment at the ready, all the aides? Are there institutions available that are excellent and welcoming and well-staffed and well supplied and happy, vibrant places, or are they dingy and sad and full of dysfunction and is it hard to find a good one?

How does the geriatrician experience the day to day? Is the office work easy and efficient, or is he or she always struggling to keep up with the documentation required by the electronic medical record that is designed to optimize billing rather than care? Is the geriatrician served by a scribe who does all the work of electronic charting, or does the geriatrician do it him or herself, acting as a data input clerk? Does the parent organization take pride in the geriatrics office, even though it is more an economic drain rather than a profit center?

Does the geriatrician skate through the day or slog through sand to the point of exhaustion?

And the pay, the pay and benefits and vacation time. All the non-procedural specialties need better pay, the current structure of pay is an out-of-control outrage. But the job can make up for lower pay, if it is really well-structured and fulfilling. Is the structure of the job, the agency available for exertion by the geriatrician, the resources at hand – do they lead to great job satisfaction? Do health care groups have a carved out gerontology slots, with attractive job descriptions and resources at hand? These are things that students will see as they make their specialty choices.

Is the substance of the job enough to offset the inferior pay? Is it good enough to make it attractive to make half as much as your colleagues to elect to become strutting orthopedists?

There will always be people who choose to follow their interests and their ideals into a chosen field, no matter the consequences for their job. They can accept the indignities because they are obeying a higher calling, and they are following their passion, their bliss. That's true of all walks of life. But it makes it a lot easier to do so, and many more will choose them, if the jobs are really well-structured, well-operated, and well-conceived.

So my advice is, Jerry, is go work on that. You can do it right there where you are. Construct an ideal operation. Show the world what you can do to make the life of a geriatrician a dream. You don't have to match the orthopedist's pay and lifestyle (but you should get close, say 80% close), but you do have to make the organizations you are working for pass your increased remuneration down to you and not just spread it around the group. Make that extra degree worth something. And make the job one where you skate through the day, not one where you are continually slogging, which takes resources and organization. Match the job to the attractiveness of the profession, and maybe then you will get to serve society with what it needs, more services for the aged provided by the proper provider with the proper organization.

What Gurwitz has missed, in sum, is the difference between a profession and a job. While the profession of geriatrician can be terrific, the job of being one often sucks.


Here's the NEJM article:

    Toward Gerineuropalliative Care For Patients With Dementia

    Krista L. Harrison, Ph.D., Nicole Boyd, M.D., and Christine S. Ritchie, M.D., M.S.P.H.

    from the New England Journal of Medicine (NEJM), August 30, 2023

    https://www.nejm.org/doi/full/10.1056/NEJMp2301347

And lo! Just a little later in the same month comes an article in NEJM, a more hopeful one, on a similar subject, caring for older patients with dementia. Where the JAMA article sees an intractable problem in caring for older people because specialists are not being produced, this article posits a model of care that, they say, could be adapted for generalists rather than geriatricians, perhaps because the geriatricians are just not available. (Again, the same dilemma arises in adolescent medicine, where specially trained personnel would render excellent service, but where numbers dictate that they be mostly researchers, teachers of pediatricians and a referral specialty.) This service model also highlights the need for non-fee-for-service payments – nothing new there – and in a hopeful sign, Medicare has started a model program where capitated care would be available. Beyond those small nods to practicality, however, the article is a rather typical academic approach to matching resources to need in an ideal world. The summary chart in their article is impressive. What a plan! I only it could be implemented!

I would think that this interesting chart would be helpful in actually shaping programs in the field, but that remains to be seen. The problem is, who would try it, and why? Yes, the ideal of helping people is always there. If a program were to be mounted in academia, the careers of the progenitors would be enhanced, and staff working on the project would find their jobs enriched. But when a field with obvious needs has shown so little progress over time, there's a reason. Here and there in the country, there would be enthusiasts to take up the model.

There are deeper questions that need to be approached to really understand this situation. Let's just mention them.

Is the country prejudiced against old people? Yes, our culture does not honor the old very much. Put them out on the ice, some urge, the gerontocracy takes up slots that should go to younger people (like the author of that screed, one surmises.) Or probably, the wealthy can often take care of their oldster problems privately, so programs that would serve everyone are not their concern.

Why does the profession of medicine allow this situation to persist, and not target their efforts toward the country's problems with primary care and chronic care? Well, the profession of medicine is not a whole, it is pieces, and the haves are the procedural specialists, and the have-nots are the chronic caregivers, the primary caregivers, the procedure-less specialties. And as always, the well off have more resources than the less well off, and they use those resources to reinforce their position of privilege.

Why do people wait until situations get out of hand to react, why don't they see the future and plan for it? Well, they're not as smart and as disciplined as you would wish. You can plan and act thoughtfully in small groups, but not the larger ones, where entrenched interests are self-protective, and not naturally inclined to sacrifice their short term interests for putative long term possibilities. Present perks are hard to fight.

But, whatever. In the field of geriatrics, if you want to do good, it's a good idea to focus on the job rather than the career. Make it a rewarding job, and they will come. An interesting profession, OK, yes, but that's speculation. The job that you can see and feel, that's what will attract new entries.

 

Budd Shenkin

Wednesday, January 31, 2024

Budd's Blood Pressure - Fascinating!

Here's a story about my blood pressure.

I know, “Fascinating! Let's hear it, Budd!” Then I'll tell you about my aching left foot – what a problem that's been!

Actually, I've wanted to tell this story since it happened to me last week, and I planned to adumbrate it with observations of the medical care system. Here's the very short version:

For some reason, I really don't remember why, after more than a year of not checking my BP, I checked it while I was in Maui, and found it elevated, to 142/84. Not a deadly level, but concerning, because one, it was rising, and two, when you get past 140 systolic, the danger of events starts to increase. And me, well, I always over-react. Can't help it.

So when I got back in town the next week I tried to get in touch with my PCP, my friend and long-time colleague Jim Eichel, who used to work for me and now works for Stanford. Stanford. A hospital, and thus, a bureaucracy. I messaged him and got back a message from a physicians assistant who said my BP wasn't so bad, and what about life-style? Give me a break. I'm a doctor with 31 years of education and over 30 years of practice, and I'm going to be talking to a PA whom I don't know? Next they'll be telling me to check in with an urgent care center, where I would get an unsupervised PA.

So I called and asked for an appointment. Sure, I could do a Zoom call in 3 weeks (you can't measure a BP in person on a Zoom call, Stanford) or I could see Jim in a couple of months. My blood pressure is rising (and this phone call didn't help, obviously) and they're telling me that my PCP isn't available. Yet they'll claim high quality care. NOT, people! Access is part of quality care, and personal contact with your own doctor is a part of quality care. Baiting and switching is not part of quality care, Stanford.

So I figured I'd email Jim privately, which I did, and in a couple of days he got back to me and wondered if we should start hydralazine, a 4th drug for my BP. He thought maybe yes. I wondered.

But in the meantime I figured, before Jim got back to me, let me call my cardiologist. I hadn't seen him for years, when I had a rhythm abnormality, but what the hell. I believe in specialist care, and if the US doesn't have enough primaries and a surfeit of specialists, I'll go with that flow. Turns out it took me maybe 2-3 days to see my cardiologist – it would have been sooner if I had been an “active patient.” Since I was just an old patient, they required a referral. Well, Stanford would be no help there so I got my doctor step-daughter to send in the referral – we regularly help each other in getting ourselves through the system. So, the fact of the matter is that I got to see my cardiologist before, way before, I could see my PCP. And actually, not only that, but then I got an echo-cardiogram and a renal ultrasound the very next business day. Eventually on the weekend I talked it over with Jim and we were all cool – I got to tell him what my cardiologist said about him, that he's the best PCP in the area. I love delivering good news. Jim is such a dear man, really, such a sincere and dedicated and knowledgable doctor who doesn't even tell me I'm over-reactor, although he doesn't contradict me when I confess that I know that I am. Jim's personal humanitarian instincts and practice are disserved by his Stanford system, seems to me.

But that's not really what I wanted to say in this post, enlightening as it is. When I visited Eric, my cardiologist, we talked more about the case, and he said he doesn't really like to add drugs if he can help it. Well, I want to stay in a good range, not a dangerous range, but I didn't object. So Eric said, it doesn't look like you need to lose weight. I could lose 10 pounds, I said. OK, do it, he said. But then, as we talked about the case, I realized that yes, I didn't add salt to my food, but I really didn't avoid it, either. And I eat a lot of prepared foods, which I knew were salty. I was just relying on my meds to counteract it. So I figured it's time for me to really make an effort.

And that's when I made my discovery. I started reading labels. Every goddamn thing has so much salt in it! My friend Mary Lou, whose son does catering, said that he adds salt to everything because it makes things more tasty. And that's what all the food companies are doing, the same thing. They are honoring sales and taste and shortchanging health. Salt just isn't good for you.

But, maybe that's an overreaction – I don't know, I overreact. So I figured, fresh fruits and vegetables, you can't go wrong with that. I'll just go that route. I try to eat a lot of them anyway, I'll just step it up. Which I did over the next few days. And, amazingly, here's what happened. Look at the BP change!  I went low-salt on the 25th, I think.

 

1-17-2024

8:15 AM

148/84

62

1-18-2024

2:04 PM

143/82

69

1-19-2024

10:10 AM

139/82

68

1-21-2024

7:20 AM

153/89

64

1-21-2024

8:40 AM

142/83

66

1-22-2024

9:15 AM

142/87

68

1-23-2024

9:30 AM

148/84

72

1-25-2024

8:45 AM

140/72

68

1-26-2024

8:30 AM

136/83

61

1-26-2024

5:25 PM

131/79

56

1-27-2024

5:00 PM

134/86

61

1-27-2024

5:30 PM

130/84

61

1-29-2024

9:00 AM

124/70


1-30-2024

7:55 AM

139/81

64

1-30-2024

7:25 PM

129/74

72

1-31-2024

5:35 PM

129/74

58

 

And not only that – when I went to work out, I got my maximum heart rate to up 151, which is exactly what my max ought to be for my age. I figure I was under toxic salt syndrome (which I just named.) How amazing is that?!

So then I went to Berkeley Bowl, our local supermarket that caters to discriminating customers, and I was able to find many low-salt items – canned tomatoes with zero salt, canned beans with almost no salt, lots of things. Plus their usual amazing selection of fresh produce.

So there it is, that's the post. I'll have to change my diet, but who knows what other good doing that will do? You just can't go wrong with fresh fruits and vegetables. Now, to figure out how to make soups with no salt – Insta-Pot, gifted to me by Sara a year ago, here I come!

Sitting down and talking with your doctor really has no good substitute, in my opinion. But then, I'm an over-reactor. But over-reactors need care, too.


Budd Shenkin


Sunday, January 14, 2024

Democrat, Republican or Independent? Friendly Debate

 

I have some friends who are frustrated with party politics. Here is what they and I write to each other:


Friend One

It’s remarkable that 43% of Americans identify as independent, while only 27% identify with R’s and another 27% for D’s – a new low for D’s.  As a card-carrying independent, I applaud the steady growth of rejection of both these miserable parties whose time has long gone. The Republicans have lost all semblance of conservative principle and are held hostage by neanderthal nihilists on the right; the Dems are awash in identity politics and woke insanity, and still absurdly believe – despite all evidence to the contrary – that government can offer effective solutions to all our social ills. Both parties are craven and amoral, self-absorbed liars who wallow in a broken system.

And yet, when nearly half of America is ready to reject them and vote independent, who do we get to vote for? RFK Jr.

 

Friend Two

Thank you for the realistic view of our parties today. And it ain’t no party!

I am still a registered Democrat although I have identified as an independent for >20 years. I share your views. I too am waiting for an independent candidate that I can support.


But I feel differently, so here is what I wrote back to them:


Me


I don't feel the same way.  I'm a Democrat and always have been.

It's useless to talk about the Republican Party.  I never liked them, even when they were a decent party.  They have always been the rich man's party, the country club party, the penny-pinching party, and in the past the anti-Semitic party, and they may be still, those of the old party that are left.  I like the old Mort Sahl line, What's a liberal Republican?  They're for change, just not now.  And now, those old me-first Republican stick in the muds, the help yourself don't look to me to help Republicans, are far too liberal for the party that has essentially been body-snatched.  It's like when SBC bought ATT and took the name, because SBC had a bad reputation.

The Democratic Party has a much better heritage, especially since FDR.  FDR - tripling down on his cousin TR - thought that government should help people, not call balls and strikes.  His Four Freedoms rang true.  One or two of you might remember my paeon to the Four Freedoms -- https://buddshenkin.blogspot.com/2021/03/finding-unity-four-freedoms-plus-two.html.  In the great questions of the day,the Democratic party has generally been on the right side.  They get a bad rap on defense -- they are not willing to kowtow to the generals, but they have always been strong.  I could go on about the virtues of their heritage.

Has the extreme Left bodysnatiched the Dems?  No.  It's a varied party, as you have to be in a two party system, and putting together alliances is always tough.  I admire AOC, but not so much her chosen lefties, some of which are horrible.  The Black caucus is a problem, whose anti-Semitism is beyond criticism.  I find some of them really irritating, and the identity politics that Rick cites is awful, just awful.  But the bulk of the party has the right attitude and the right tilt.

Have government programs failed?  Not really.  The best ones are those that write checks -- social security, Medicare, Medicaid.  Where would we be without them?  What about nutrition programs for the poor?  So many others.  Government can't offer solutions for all social ills, of course that's true.  I don't know who believes that it can.  But it already does so much, and could do so much more if given a chance.  If you look at the social welfare democracies of Europe, especially Scandinavia, you can see how a government can lift up a whole country over time.  Sweden was known as Poor Sweden, until the Social Democrats took over about 100 years ago.  Now they are world leaders in a country not blessed with many natural resources.

Is bureaucracy a failure?  Often, in this country.  Can it be stupid and stultifying and frustrating?  In spades.  The trick is to devise programs and policies that avoid large bureaucracies, or that decentralize enough so that there can be competition within government.   I think, for instance, that Medicare should split up into smaller units to administer the program, and compete against each other.  That's a question of design, and there are many others.

In a two-party system, in many ways it makes more sense to choose the party instead of the individual candidate.  We all love the great legislators, but when push comes to shove, would you rather have a pretty good Republican or an average Democrat?  It's the vote that counts.  There will always be leaders and followers in organizations, and the House and the Senate are organizations.  Overall, much as I detest her personally (can't say why, exactly) and vote against her in every election, it's better to have Barbara Lee in the House than any Republican that runs against her, no matter how great, because it's their votes that count.  Want a great Republican thinker (there must be some) who votes with Marjory Taylor Green on every vote?  What good is that?  Unless the Republican you elect is leading a group to a new Republican party and is willing to vote independently, a vote for any Republican is a vote for the body-snatched party, a vote for Trump and his acolytes. 

Parties serve a function in our democracy.  I find much to criticize in the Democratic party, and not just on the radical left (which, given the conservative structure and function of politics in this country, would be center or center left abroad).  I decry their gerontocracy, their suppression of competitive primary elections, etc.  But without them, we would live in chaos.  If there were more parties than two, we would soon be subject to the same woes of other countries like Israel, where a small swing faction gets to have its way.

And that's the way it is.

Budd


Friend One


As always, it’s a delight to read your thoughts, Budd. Much of what you say is persuasive, and all of it is so forcefully and mellifluously presented!

Just a few points in reply, please.

First, it’s telling to me that, when you talk about the Democratic party, you’re somewhat forced to look way into history, rightfully extolling the pedigree that FDR (and TR before him) laid down. I share your deep admiration for both of them, but that’s almost a century ago. It has limited relevance, in my view, to those who populate the party today. Yes, the Dems have long been the party of compassion, but I see woke culture – which permeates not only politics, but almost every aspect of modern life – to be the antithesis of respect, tolerance, inclusion and the celebration of diversity (in all its aspects). Today’s Democratic Party is awash in identity politics, and you acknowledge all the baggage that comes with it: racism/anti-racism, antisemitism, character assassination, mob rule, the dumbing down of academic standards, the polarization of our society.  I know you see all that’s wrong with this party today – you say so – so I won’t go on and on.

Ironically, the best argument for the Democratic Party right now, in my view, is the job Joe Biden has done as President. He gets little credit for it, and the overwhelming view – of all Americans – is that he should not run again. But his presidency has been remarkably strong, in both domestic and foreign policy.

The real question is, where are the visionary, talented Democrats who are leading the party to a better future, post-Biden? I submit that they are nowhere: not my pal Cory Booker, who has about as much support within the party as my dog, Ollie; not Gretchen Whitmer, who ought to be their candidate for President, but no one in the party had the balls to try to make that happen. Not Pete Buttigieg, who has disappeared altogether within the Biden Administration. And certainly not Kamala Harris, the heir apparent who is rightfully loathed and disrespected by everyone in the United States, in both parties.

So I don’t hold the brief for the Democrats that you do. (Being an independent in Maryland is pretty comfortable: we have plenty of good Republicans to vote for on occasion, like former Senator Mac Mathias, former Governor Larry Hogan, former Congresswoman Connie Morella, along with many great Democrats like current Governor Wes Moore, both our US Senators and Rep. Jamie Raskin.)  

In general, we agree completely about the Republican Party. No discussion needed there.


Me

Thanks, as always, for the compliment!!  Warms my heart and my figurative pen.

The greatest sin of the Democratic party is not to provide for the future.  The best companies identify, recruit, nurture, and promote talent, and meld all the talent into teams that produce and provide for the future.  The Democratic party hardly does this at all.  There's lots of work we don't see -- candidate recruitment, for instance.  But the talent that's there gets crushed under committee chairs who stay forever -- in contrast to the Republicans, by the way, who term out chairs.  And they don't sunset.  And they don't have ways to bring governors into national spotlight, as they could by having commissions to approach problems, for instance, composed of governors, cabinet officials, leading legislators.  It's a severe organizational problem.

Our era has been conservative, ever since 1980.  Even the Clinton presidency championed neoliberalism, conferring further impetus to inequality.  The lack of caring for the middle, working, and lower classes has been a hallmark of these YOYO years, even with Clinton.  Instead of real programs and tax policies to help those classes, we have devolved into minority care, with Hillary nearly running out of breath as she listed the minority groups her administration would help.  It's a mark of progress that Biden talks more about helping ordinary people in general.  One idea he took up, but which the Republicans have let lapse, was Rosa DeLauro's child tax allowance, which lifted about half the children in poverty out of it.  He also has been trying to revivify anti-trust, as Bork and the Chicago School and the Republicans have allowed concentration of business entities to run rampant, even giving them the rights of citizens in elections, as we know.

So, given that conservative environment, we can't point to big wins as in the previous era.  In fact, just look at tax policy, and we can point to big losses.  But I have confidence, perhaps misplaced, that eras change, and given enough time in power, the Democrats would regain their senses and concentrate on lifting all boats.  After all, it's their legacy, and enough believe in it that I think it would reassert itself, given the right environment.  And as in the late 1930's, a major obstacle would be a recalcitrant SCOTUS, that will have to be neutered somehow, someway.

And I would be remiss if I didn't mention that it is even possible, given some longevity of Democratic governance, that Modern Monetary Theory will be given a good test!  And that we will find governmental policies to help us transition to a new society where increased productivity is translated into increased leisure and security for all.  And where climate becomes a #1 priority.

Dreams are the salvation of life.

Budd

 

Talking with friends is one of the great pleasures of life.

 

Budd Shenkin


Saturday, January 6, 2024

Is It Reasonable To Focus On Biden's Age?

Is President Biden too old to be running for a second term?  You might think so – 81 is a big number, with 85 looming 4 years later.  On the other hand, you might be wrong.

As a physician, I’m used to looking at risk factors.  Being old is just a risk factor, just as being heavy is a risk for diabetes, or getting sunburned frequently is a risk for melanoma.  You’re at risk, but you may have it and you may not.  So we see the risk and we test for it.  

What is the risk for being old?  There is a dreadful stereotype of an “old man,” someone who dodders with a frail body, weak memory, depleted energy, compromised reasoning ability, someone who lives in the past and is liable to collapse at any time.  Let’s call that Type 1 — it exists, but it is not inevitable, just because you’re old.

There is also a Type 2 old man, an “old fox.”  He might be a seasoned leader who resists the impulses of the moment, whose patient judgement weighs alternatives and possible consequences, whose experience enables him to make government work, who knows the people and the terrain of the country and the world, whose years have earned him wisdom.  Think “greatness of spirit” rather than “old and broken.” Think secure and clever and wise.  As Ronald Reagan put it in 1984, “I think it was Seneca but it might have been Cicero who said, if it were not for the elders correcting the mistakes of the young, we would have no state.”  Especially nowadays, in the age of modern medicine, it is increasingly likely that a man of 80 might be this Type 2.

So, just as we observe Biden, is he Type 1 or Type 2?

His stiff walking posture probably betrays some spinal arthritis, which does not interfere with doing the job.  But his health seems excellent otherwise, and there are no reports and no evidence of mental decline.  In fact, his presidency has been the most productive since LBJ, his schedule is more rigorous than George W. Bush’s was, and he travels extensively and meets all over the world.  It’s true that he stumbles over words, but that is nothing new for someone with a history of stuttering.

In short, the evidence we have points to Biden as being Type 2, someone who has grown with age, rather than shrunk.

It’s true, however, that illness can come quickly to an older person.  It is also true, however, that bad things can happen suddenly to younger persons as well — think JFK.  After the Kennedy assassination, Congress passed the 25th Amendment, providing a procedure for replacing an ailing President, whether they recognize it themselves, or whether it is the decision of the Vice President and a majority of the Cabinet. Beyond that, staff and advisors function as teammates, supporting and supplementing when health problems arise.  The procedures to take when a President is ailing are there, even though it can be admittedly difficult to administer them.

In addition, we should also think about this - is it reasonable to center our concern on Biden's age, above other considerations?  Yes, there are risks to age, but think of all the other risks that we have with presidential candidates.  Think of everything that can go wrong when you hire someone.  There is alcoholism, depression, anxiety, sleep deprivation, delusions, sociopathy, corruption, chronic anger. Indeed, a candidate might be quite literally crazy.  There is lack of good intelligence, bad work habits, laziness, dishonesty, lying, ties to foreign powers, prejudice.  What about the ability to think through problems, to build a team?  What about breadth of knowledge, a tendency to make a country more peaceful rather than more contentious, knowledge of government operations, executive experience and ability?

Age is but one factor among many, and to focus on that one factor and to ignore the other risks seems unreasonable.  Biden seems to have evaded the bad consequences of aging and has garnered the positives.  Like a well worn shoe, Biden is a known quantity who has proven reliable and effective, even surprisingly so.  We should judge the man by his abilities and his character and his history and the fact that he is Type 2 older person who has gained wisdom, not one who has withered.

The odds are, Biden will still be driving his Corvette wearing his aviators when the next President is sworn in, in 2028.

 

Budd Shenkin

 

Note - a form of this post appeared as an op ed in the San Jose Mercury News on January 11, 2024 -- I thank David Levine for his editorial help, as always.

https://www.mercurynews.com/2024/01/11/opinion-is-it-reasonable-to-be-concerned-about-president-bidens-age/

 

Friday, December 22, 2023

Integrity vs. Despair

 

I've been pretty unconscious about it. Since I've passed 80, unimaginably and contrary to all expectations – mine, anyway – and since my wife has passed on – unexpectedly, despite her long illness, I never expected her to die on me – since I've passed 80 and I'm living alone, although I have friends and family I retire to our house where I am alone with my computer and my television and my refrigerator and several bathrooms, I now proceed through each day with some idea of where I'm going, what tasks to accomplish every day, because I do insist on accomplishing something everyday of either urgent or long-term implications, even if it's just putting some stuff in order that I've been wanting to do, and I don't plan a lot of the rest of what I do. It just kind of happens, in a way, although it all seems purposeful.

So it seems I'm seeking my past and in a way stitching it together, not respecting time very much at all. I'm reaching back to the different parts of my past, the people in my past, and some of my past activities. My past activities seem to be centered on my pursuit of learning and my school days. I take French, study it each day, read French books and love it, I lie in my bed and read and underline and I study French on my computer and I write little notes like this, and I write a chapter of my French novel each week – up to chapter 286 this week. I love my characters in the novel. Who would have thought that that's what I would do?

And now I take advantage of my own and my contemporaries' longevity and the abolition of long-distance charges, reminding me how much of a curse AT&T was, years of high charges and stagnation. It's actually amazing. My past is studded with friends who still exist and who will still talk to me or write to me. My oldest friend is my brother Bobby whom I have known since I was 2 years 8 months old, although I don't remember when we met; according to me, he was just always there, a little bit smaller than me. Then there's Bob Levin, from kindergarten, John Raezer from nursery school originally, and then he was my high school friend where he was a God and then roommates in college and friends ever since. My high school friends, a bunch of them, Lynn Sherr whom I love to introduce as my friend for the last 65 years, Jonny Fish who lives nearby and Jon Gross from fifth through 8th grade and then high school, and my med school friends, lots of them now, and Tom Uridel and Jim Perrin from the Public Health Service, and so many more contemporary friends from practice from the neighborhood from book club from our new friends in Maui and so much more.

It's like jewels on a belt of time that you can lie out flat and see the periods, and rub whichever jewel you want, or roll it up and then the different times are right beside each other.

They say that you take stock of yourself at my age.

Integrity vs. Despair – According to Erikson, the last psychosocial stage is Integrity vs. Despair. This stage includes, “a retrospective accounting of one's life to date; how much one embraces life as having been well lived, as opposed to regretting missed opportunities,” (Erikson, 1982, p. 112).

So you do, or at least so I do, but it's not as serious as all that, and it's not mournful – well, maybe a little – it's more grateful than that. It would be even better if I could revisit the women in my life – I wonder what happened to those women friends in Sweden, when I was so desirable but so confused, but also very fulfilled. I'd love to see them again. I really should go back there and visit Annika, although I'm lacking an invitation.

But what I wanted to mention was the conversation that I had a few days a with John Wesley, a friend from Leverett House in college and from med school. I called him out of the blue – why not? I have his number in my contact list and, as I said, calls are free these days, amazingly, and we have the equivalent of Dick Tracy's wristwatch radio, called a cell phone. I talked to one of my college roommates, Arthur Freeman, last week, he just up and called me, on Raezer's urging. We talked for an hour and 45 minutes, picking up where we left off, although it's been about 60 years. We had to catch up.

But in talking to Wesley, he reminisced about being a resident in surgery at the Mass General and his fellow resident was John Erdman, another friend from college and med school both, who committed suicide as a young doctor. There are various theories, I guess, and I don't know the facts, really. I did hear he plugged himself into an IV and infused something fatal as he lay on a gurney. But the story John told, with a humorous lilt in his voice, strangely, was how their chief resident demeaned John in front of all the assembled residents for not knowing some basic data, the hematocrit, of one of his patients. He said something about “Sweet baby Jesus” having a task for everyone and if everyone doesn't do it then it doesn't get done. A public putdown. John thought it was charming and funny, somehow. But I can imagine the emotion Erdman must have had, and the fact that he later did himself in, and I can't help but connect them, and I can't help but think of the inhumanity of the hospital setting for trainees, just when the tension is so great and the relief and support so needed. I remember the small provocations I experienced. I think of what my med school friend Larry Kadish just related last week in our Humanistic Medicine Initiative discussion, when he was serving a medicine rotation as a resident and a new patient was admitted from the ER and turned up on the ward dead. Here's the way Larry put it:

Although I had a surgical internship, every surgeon in our program had 2 months of medical rotation. My rotation in medicine started July 1st.  My first patient had an MI and was sent to the medical floor from the ER.  I examined him as soon as he arrived, but he was dead.  After informing the family, I called the second year resident to inform him.  He said I was lucky to have a Q-C.  I should go to bed.  A Q-C was a quick cool.  So much for humanistic values.

I guess that qualifies as taking stock of myself, or ourselves. I figure that our HMI, seeking to help students appreciate and solidify humanistic medical values and activities, is part of reassessment, taking account, and then doing what parents do when they lose a child, try to prevent others from suffering our fate if it can be avoided. Look back and repair, if not for yourself (time's arrow takes care of that), then for others. In our case, help the current students to at least understand the pressures they will be under to lose their humanity as they become professionals.

But it's not all grim, unless I dwell on my failures and embarrassments, which are so many. But I do have my strengths, which might be overrated, but it's pretty amazing how time has continued, and how I can make a claim to a successful life, even in terms of helping others, which I suspect of conventionality. But there it is.

I guess it's no sin to be conventional.

Budd Shenkin

Friday, December 1, 2023

Newsom Could Sharpen His Defense Of Biden's Age

I caught the last part of last night's Newsom-Desantis10-rounder, a worthy undercard for what's perhaps to come. I don't like these face-offs much, dispute for dispute's sake, don't stick to the question, no premium on clarity, and Hannity is a disgrace – tilted questions that weren't even disguised. But given the form, Newsom is formidable, and Desantis was persistent in his execrable opportunistic right-wing lying points.

But as strong and prepared as Newsom was, he could have done better on the Biden-age thing. Hannity and Desantis both harped on the “obvious truth” that Biden isn't what he used to be. Newsom replied that he has been a terrific President, getting so many things right. Which is true, but it isn't quite direct enough, to my mind. It doesn't spell it out. I spell it out in my post here, but here's a shorter reply that Newsom could have adopted, and that other Dems should adopt as the campaign progresses.

The best answer to that is this: right! Of course he isn't! We all change, for the good and for the bad, all the time, as long as we're alive.

But it's a balance. You get better at some things and worse at some things. As you get older, your numerical calculation skills decline – it's hard to divide and multiply in your head. But, you also get smarter with experience, you gain in wisdom, you've seen a lot more. When you're young you might have more energy – although Biden is still tremendously full of energy, just look at this schedule, what he's done around the world as well as at home! But when you're young, you don't know as much, you haven't been around the track as much, you are more impulsive, less patient, you have gained less wisdom.

Reagan was right in his debate with Mondale – he vowed not to make an issue of how untried and inexperienced Mondale was.

Who knows more about government and getting things done than Biden? Desantis? GMAFB. Who knows more world leaders over more years – an indispensable advantage in foreign affairs – than Biden? For that matter, who knows people all over the country, and understands them?

Yes, Biden's walk has become stiff; there is some arthritis, no doubt. He sometimes has trouble with words – but that's not new, and in the end, it doesn't matter. He's still sharp as a tack, he's still solid in his values, he knows how to be patient and go one step at a time, but he also knows how to act at the right moment, to be decisive, to be sharp and on point and seize the day. He still knows how to relate to people in and outside of the governing process, and that is indispensible.

On balance, he's better than he's ever been, and we're so lucky to have him.


Budd Shenkin