Sunday, December 30, 2018

NBA All Star Weekend -- Territorial Pick 3 on 3 Tournament!

We all come from someplace. From the very first, when all that exists for us is our mother and us, to when it includes daddy and sibs and neighbors and schoolmates and other schools we play our games against to summer camps to select teams to college, way up to the NBA itself, no matter how far we ascend, we all come from someplace. We know our origins, we are fond of our origins, we honor the people who made us who we are, and we are thankful, nostalgic, and even patriotic about where we come from.

Me, I'm still a sucker for Philadelphia, even though I've lived in Berkeley for 45 years. Philly is where I grew up, where I had my first hoops outside my house, who knows why my Mom insisted that we have hoops outside our houses, but we did, all three of them, each one higher than the last, up to 10 feet finally. Philly is where I finished my homework by 8 o'clock so I could watch the Big 5 compete on Channel 12 from Wilmington in black and white. God, I loved Guy Rodgers and Temple, and St. Joe's! And my high school teams, you probably heard about my high school, Lower Merion. I tell people that my own crossover move, copied through the years at LM, is what later sent Kobe on his way. It's a nice joke.

While my first hero was Joe Fulks, and then Paul Arizin, the overriding superhero of all was, of course, Wilt, from Overbrook High, just northwest of me when I lived in West Philadelphia, and just southeast of me in Lower Merion. Wilt, the God. How strange it seemed when he up and left for Phog Allen and Kansas for college! What was he doing in those cornfields? Especially a black guy? And then the Globetrotters as he waited to come to the NBA. In those days the college game was bigger than the NBA, and truth to tell, there were a bunch of Jewish guys and other what we would now call “minorities” or “ethnics” who were trying to create and sell the pro game. So they knew that guys like me knew who “our” guys were. They were the guys who came from where we came from.

So, to promote interest, the owners laid claim to their own guys, guys who grew up there, or at least went to college there, which was frequently the same thing. Thus was born the “Territorial Pick” in the draft. The Philadelphia Warriors got a bunch of guys that way – Arizin, Rodgers, Ernie Beck from Penn, Tom Gola from LaSalle, and then Wilt. ( You can look it up. Our guys were our guys, and we cheered for them, and loved them.

Philly-ball was different from New York-ball, from Chicago-ball, from Indiana-ball, at least that's the way it seemed, and our guys were our guys. Sometimes you still hear in interviews with the players how they heard of other guys growing up, how they played with and against them, how they still have that sense of where they're from. Now that the NBA is so big, so worldwide, they don't need that localism anymore. Now that free agency has been established – a good thing – and now that fantasy teams are so popular that the NBA GM's and even the players themselves play it with real teams like Miami and the Warriors, we're used to non-localism. But, that doesn't mean that localism is dead. At least I don't think it is. Especially in my mind, it isn't. I still sit and watch, me in my chair and Ann on the couch at 90° on the other side of the side table from me, and I'll say – “He's from Philadelphia!” And, from another sport, every time Hallie Jackson or Jake Tapper says something about the Eagles, I say, “Eagles!” and Ann grins and puts her hands over her eyes as if to say, “Oh, no, Philadelphia again!”

All of which is a long-winded way of getting around to my very practical suggestion. The league has wisely tried to make All Star Weekend an entertaining event time, with the three point contest and the dunking contest. All that's missing is the players game of Horse – hey, come to think of it, wouldn't that be great??? Or Team Horse??

But I digress; that's not my suggestion. My suggestion goes back to localism. What I'm proposing is this: a 3 on 3 Territorial Pick Tournament. 3ON3TPT – why not? Here's how it would work:

The teams would consist of players who grew up in the same place, specifically, where they went to high school. Each team would have an organizer, which could be a retired player or a current player, and they would choose five players a piece, three starters and two subs. The games would be 15 minutes long, half court, and the subs could come in only once. Retired players would be eligible – if Wilt were still around, he could have played until age 70. It would be The Chicago Guys vs. Philly Cheesesteaks; Bay Area Bombers vs. LA Slugs; North Carolina Stalkers vs. Indiana Larrys. The Serbian Sluggers. Maybe have 6 or 8 teams a year with single elimination.

It could work lots of ways, but you get the drift. Bring back Where You're From, back from the chaos of free agency and fantasy leagues. We all have a sense of where we're from. That never goes away.

Tell me that wouldn't be a winner!

Budd Shenkin

Sunday, November 18, 2018

What Price Nostalgia?

I'm pretty sure my now-classic Omega Seamaster watch was a college graduation gift. It must have been my Aunt Bea (actually my maternal great-aunt) who gave it to me. She gave me mother of pearl cuff links for use with a tuxedo when I graduated from high school and was set to go to Harvard. She had a taste for the finer things, and a taste for formality. It's kind of funny to think of what she thought would happen at college, vs. reality. For her, Harvard equaled formal social events. My paternal grandmother, another Eastern European immigrant, was overwhelmed when she heard my next door neighbor in the dorm was named Sam Saltonstall. “Stay close to him,” was her advice. She didn't know that Sam's main passion was his trumpet, and I think the famous surname weighed on him. My God, they must have thought, from immigrant to Harvard in two generations. What a country! I don't think they knew I was there to work, hard. But what the hell.

Aunt Bea was the eldest of the five Chertak sisters, “Litvaks” my father claimed, an industrious group full of hopes, I imagine. Bea had become a Philadelphia socialite. Mysteriously to me, she would arrive at our house in her Buick driven by a uniformed chauffeur from her luxurious house (at least luxurious to me) on the Main Line. But grand and blond as her entrance might have been, what arrived to the four of us kids was the warmth she exuded from her corpulent body and outstretched arms. With no children of her own, we were as close as she was going to get. How she had arrived at her chauffeur-driven status we couldn't guess, nor how she had become a socialite, which had included her membership on the board of the Robin Hood Dell, the outside summer setting for the Philadelphia Orchestra. Later on she moved into town at the Rittenhouse Plaza with her likewise childless sister Sadye. We visited them often; they noted affectionately how we liked to eat the nuts which they had on a silver platter on a coffee table, beside a slim silver bowl with a few cigarettes. As an awkward teenager with a photography hobby, I took pictures of Sadye's late in life second wedding at their apartment. I developed them and enlarged them myself, and some of those pictures were on constant private display under the thick glass table tops of their bedroom bureaus. They were still there when Sadye died and all the grandnephews and nieces reviewed the remaining contents of their lives.

My father complained that other husbands only had one mother in law but he had five – our holiday dinners included my grandmothers, Sadye and Bea, sometimes Dorothy and Bill from New York, and sometimes others. A big crowd in a small suburban development home. My Dad resented how many relatives there were on his wife's side – I don't think he thought that they sufficiently respected his rightful status as king, or maybe he just felt like an outsider with only his mother representing his side – and he seemed to resent especially Bea's pretensions, but we loved her warmth. We loved the family playing 21 (Blackjack) after the table had been cleared, with the kids “helping,” and Uncle Bill going “bank-o!” with his bet, and everyone saying “Oohhhh!” at his wild sally. When I was in high school we had a nickname for Bea, I think initiated by my friend Ed Packel - “Wide Zorch.” Even though it was mildly derisive, she loved it. When she would arrive at our house, she would say, “What is it you call me?” We would giggle, “Wide Zorch!” She would say with her widest smile, “I'll Zorch you!” I can't help smile with tears in my eyes, verily as I write this. Aunt Bea, what a character.

Aunt Sadye would reminisce about the 1920's. “They were wonderful,” and she'd shake her head a little at past enchantments. It might have been something like our 1970's. In the 20's Bea and Sadye would spend summers together in Paris every year. I have a couple of menus, one inscribed to Bea from “The Major,” whoever he was. I framed it and put it on our wall. Bea's French pretty much stopped with “Comment ça va,” I think. But when she said it, it was with brio. The memories.

We never heard that much about their history, at least I didn't, but I heard some from my sisters, who probably heard it from my mother in girl-to-girl talk. Turns out that Bea had gone to work as the secretary of the owner of a big Philadelphia department store, House of Wenger. Before you knew it, Mrs. Wenger was out and Bea was in. At least that's the way I heard it. Or maybe he was never married, but I think he was. In any event, that explained the money, which in turn explained the social standing. He was older and gone well before I arrived, but Bea was very much there until I was in medical school. The last I saw of her was when I came to see her in the hospital and all I saw was her going to some test on a gurney, and she looked my way and said, “Buddy!” with hope and connection to her world of love, and then off she went. Like the last time I saw my Dad in his hospital bed on a Friday night as I flew into Philadelphia from San Francisco, and his “girlfriend” at his bedside said, “Buddy's here!” and I showed him a short video clip of The Producers, his favorite show, on a portable video players, and he smiled and pointed at it – another cherished memory of laughing – and in the morning I got a call that he was gone. What are you going to do?

I think it was Aunt Bea who gave me my Omega Seamaster watch when I graduated from college. Probably. My father marveled at it, I think. He told me how special it was. It was almost like it was a present to both of us. I'm wondering if he could have given it to me, but that's not the way he rolled, and proud as proud could be of me, his gifts were more utilitarian. I owed nothing for four years of college and four years of medical school, there was never any question. I took it with gratitude, but he never asked me for that. All I had to do was to do my best, which I did, and the bargain was complete.

I wore that Seamaster for years, I replaced the strap a couple of times and finally came up with a Speidel expandable band, but then other watches came, the Seamaster lost its crown at some point, and I kept it in the top drawer of my Nakashima dresser for decades. A few years before he died at age 92 when I visited my father in Philadelphia, he pulled out his new watch to show me. It was one of the first digitals. He said, “I finally got the watch that does everything I want it to do! Here it is. And I got it for free from my dry cleaner!” I guess it was a Casio, but it could have been a Timex. Date and time, and probably even a stopwatch, all powered by a little battery.

It's true, I'm my father's son in so many ways. For years now my watch has been a Casio. The latest version is a Casio W-201, $15.68 from Walmart. It did everything I ever needed; what could be better as I went from exam room to exam room? Indestructible; let my patients pee or poop on it, I don't care! The band wears out before the battery dies, amortized at what, $1.75 a year? Comfortable, waterproof, you don't have to move it on your wrist to activate a self-winding feature.

Of course, practicality isn't everything, is it? The Seamaster is just what my admiring father said it was, a classic. In these days of watches as jewelry, even though I eschew jewelry for myself, there it is, I have it. It wouldn't be wrong to wear it for, I guess, occasions, or even every day if I wanted. And its a twofer. I look at it and I remember, not only Bea and the family, but my place in it, her love, my Dad's love, the original family, their pride, their foibles. And the jewelry part is just a throw in, although I can point to it with pride.

No need to choose. It cost me $750 to clean up the Seamaster, add a new crown, and add a nice leather strap. Estimated value of this classic, $1,250. Estimated value of the superior functioned Casio, $15.68 minus two years of depreciation. I'm wearing them both. At different times.

In the end now, at least for the present, it appears that I prefer the Seamaster. Not for the luxury, that wouldn't be Shenkinesque. For the memory, for the feeling. I like it. Works for me. The memories. The mysteries that were never explained.

I wonder who this guy The Major was?

Budd Shenkin

Thursday, November 1, 2018

The Midterms and the Dem Organizational Problem

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

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

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

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

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

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

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

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

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

I do.

Budd Shenkin

Monday, October 22, 2018

Lying Is The Message

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

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

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

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

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

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

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

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

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

Budd Shenkin

Wednesday, October 17, 2018

How Would Hyman Roth Have Handled The Khashoggi Murder?

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

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

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

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

"Give it to Rocco."

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

Budd Shenkin

Wednesday, October 10, 2018

The Hazards of Hospital Care

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

The Case of Ilana Yurkiewicz's Father

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

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

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

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

Details of the Case – What Went Wrong

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

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

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

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

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

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

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

Analysis - Hers

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

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

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

My Analysis

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

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

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

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

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

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

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

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

Two more points.

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

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

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

Common goals my foot!

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


Budd Shenkin

Thursday, September 20, 2018

A Letter to the Warriors

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

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

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

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

Sincerely yours,

Budd N. Shenkin, MD