Monday, March 24, 2014

My Pen Pal Alla, and My Friend Victor Lvov

From my American Academy of Pediatrics, Section on Administration and Practice Management (SOAPM) listserve:


Don't forget, that there were very few reasons for someone to be kicked out of medical school in my times...

Killing someone, applying for leaving Soviet Union as an "enemy of people" or... failing the very important for all physicians communist ideology class. We had 4 years of internal medicine studies, 4 years of surgical studies, 4 years of military training studies (we all graduated as second lieutenants of the soviet army reserves) but all 6 years of mandatory brainwashing where we had to take detailed notes of all historic publications (Marx, Engels, Lenin) and modern (Brezhnev's "literary" writings along with the party resolutions and other documents). I was able to swing though the dialectic materialism, historic materialism, scientific atheism and communist philosophy courses by doing research on philosophical views of Avicenna, but even the great Maimonides was able to save me from the history of Communist Party in my freshmen year and Political Communism in my senior year. Our 3 mandatory graduation exams were: (a) Medicine, (b) Public Health, (c) Political Communism. And that is on top of all the similar brainwashing through grammar, middle and high school.... To be allowed to present my PhD thesis I had to take another 3 exams:  specialty (i had to do two there - dermatology and medical genetics), foreign language (I can tell you one day how I was GIVEN that exam) and communist philosophy. 

...In 1989 despite of losing everything, uprooting everything and coming to the US with retired parents, 5 yo son, 2 suite cases per person, $90 per person in a pocket, and a dream, I did feel very optimistic. Scared - the lives of 3 people were depending on how I will be able to survive in this new country, on me and me alone - but optimistic. The best description of that feeling was that I had nothing to lose except for my own (socialist) chains, but I could get the whole world (of American dream).

Alla Gordina

And I responded to Alla:

Here is the story of my friend from Russia, Victor Lvov. 

Victor was a dear, warm friend, although we didn't socialize.  He came from St. Petersburg.  I met him when he was our neonatologist at Summit Hospital in Oakland, and I was the Chief of Pediatrics.  We worked together for years, with the warmest relationship ever. 

Victor had been a wunderkind (sorry, German word) and got his doctorate before he was 20, probably.  He was friends with the Saint Petersburg chief of police and they went fishing together.  Victor then published samizdats on the real statistics of public health, not the false ones published by the authorities.  He was told not to do this but persisted.  One day he got a call from his friend the chief of police that was very impersonal, telling him he was an enemy of the state, how could he do this anti-social activity, and that he, his wife, and his young child had to leave the Soviet Union within 24 hours.
Victor hung up the phone and thought, "He is saving me from the Gulag."
Within 24 hours Victor was in Boston with a few suitcases and his family and no money, knowing maybe one person, I think.  He was rescued by the local Jewish agency and was soon working on polishing floors with other Jewish refugees and had a small apartment for his family.  He knew no English.
Within 18 months he had mastered English and passed the medical exam.  He moved to San Francisco and started a neonatology fellowship and in a few years wound up with the Oakland neonatology group.  He was a great doctor, and was soon circulating figures that showed that Summit Hospital had the largest concentration of neonatal syphilis in the country.  We also had outstanding diagnosis and treatment results.  We completely rocked.
By the nineteen-nineties Victor and Barry Phillips, the head of the Children's Neonatology Group, had started the Heart to Heart program linking Children's Oakland to St. Petersburg Children's Hospital Number One as sister hospitals, with neonatology and pediatric cardiology and cardiac surgery.  Then a team from Children's was slated to come to St. Petersburg to consult for a few weeks.  There was a hitch -- the St. Petersburg group said that they could come, but Victor could not receive the Visiting Professor title because of his history.  Barry Phillips stood up and said, if that didn't happen, there would be no exchange at all.
Victor was then appointed as Visiting Professor and returned to St. Petersburg with the highest honors.  Victor was the true victor.  You can imagine!  Many exchanges followed back and forth, and I was lucky enough to be one of the personnel in the exchange.
Several years later I made rounds one morning at Alta Bates Hospital nursery and hadn't seen Victor in a few months.  Gil Duritz, the chief of neonatology at Alta Bates (and father of Adam Duritz, lead singer of Counting Crows) said to me, "Did you hear about Victor?"
I said, "No, what?"
Gil said, "He died last week."
"He wasn't feeling well for about a month and finally checked with a doctor.  He had lymphoma.  He did within one week."
That is the story of my friend Victor Lvov.

Budd Shenkin

Tuesday, March 18, 2014

The Ukraine

Dear readers, please allow me a somewhat disjointed post, perhaps, in the interest of topicality:

I have had a vigorous conversation with members of my family on the Ukraine.  My brother-in-law Jim is very conservative, tends strongly toward the ideological and even the pontifical, but for all that is a very nice man, and one with whom I seek reasoned agreement.  Sometimes it’s possible.  There’s something to be said for conversations within family where you can maintain an emotional equilibrium and appreciation for seriousness of purpose.
Jim thinks the West has been weak, Obama terribly so, and that the Soviets – I mean the Russians – have been more or less invited to be aggressive.  I read The Obamians by James Mann two weeks ago, and I see that Obama has wanted to be fresh and non-postVietnamian, and to lead to an era where everyone understands win-win.  I also have read others who say, lots of luck with that!  See my friend Michael Nacht’s oped on that point of view:  Michael negotiated with the Russians on nuclear disarmament in the Clinton Administration and he just shakes his head with the memory.
On the third hand, I’m reading cold-warrior Bob Gates thoroughly engrossing and so-far inadequately reviewed (they just look for dirt to dish) new book “Duty,” and he says that in recent decades the United States has treated Russia with disrespect, insensitivity, and arrogance.  Wow, coming from Gates.  The “Ugly American” is an image that will not die.  (“Ugly American” as popularly conceived; actually, as drawn by Eugene Burdick, the Ugly American was actually a positive person who happened to be physically unattractive, I think, but his aggressive colleagues in the CIA and American business have garnered the stereotype.  I mention this only to show a modicum of erudition.)  In that sense we have goaded Putin to assert himself when the opportunity and perhaps necessity has arisen.
That all being said, what I said to Jim was, I still think we'll just have to see.  It's not all over in a fortnight.  The Crimea is historically Russian, and it is unrealistic to ask Russia to give up their warm water port.  Perhaps they have been paranoid and worried that it would go away when it wouldn't, but this move of theirs ensures that they will keep it, and Putin shows strength domestically in the way he is doing it.  But at the same time he will be losing abroad and be more isolated, but perhaps there is some splendor in that.

I actually doubt anything more will happen.  Over the longer and more important term, the major job will be to get a functioning democracy going in Ukraine, a formidable task given the Ukrainian kleptocracy that has put other kleptocracies to shame.  Yanukovich seems to have had palaces, for God’s sake; Yulia Tymoshenko was a thief, too, who probably actually did belong in jail, I figure.  Here’s the question: can the technocrats produce a government that allows the country to move forward?  That's the real challenge.
You remember the intercepted phone call of Victoria Nuland's when she said, "Fuck the EU."  A noble sentiment, that.  Attention focused on the expletive and her attitude toward an ally, but titillating as that was, the key was that she was talking about helping to get a real government going.  That's what Putin objected to, all the meddling of the US.  Her seeking good government was interpreted by Putin as meddling to achieve a Western ally.  Both were correct.  What Putin misses is that the US would have liked to have Russia as an ally as well – that’s the win-win perspective that has gone missing in the KGB perspective.

The biggest problem really is Putin's Russian economy.  It grows but doesn't reach modernity.  It remains a resource state, a petrostate, and typical of these states, doesn’t sufficiently develop human capital.  What is to be gained by grabbing more territory, if that territory is simply some glory and some rustbelt?  If people in the new territory continue to be impoverished compared to the people across the border, Putin will lose.  That's what has motivated the Ukrainians - they see the Poles across their border with good lives, and they themselves are stuck in the muck.  That's why a good government is essential.  (For an over-rated exposition of the centrality of good government in economic progress, see: Why Nations Fail: The Origins of Power, Prosperity, and Poverty, by Acemoglu and Robinson.)

Not to be too Marxist, but the economy will tell the tale.  I think my brother-in-law Jim on the Right will join me in that assessment.  Right meets Left?

Budd Shenkin

Saturday, March 1, 2014

The Problem is Price, not Utilization

OK, stop me if you’ve heard this before, but I understand we have some new readers, so here are the latest horror stories from my AAP Section on Administration and Practice Management colleagues on the Listserve:

From Sue:

OK...this goes deep into You are $#%^ kidding me, right?

So, I slipped getting of our hot tub a few weeks ago (yes, one extra glass of champagne) while we were at our beach house in NJ. It was 11:30 at night, laceration on my forehead below my hairline. If I had dermabond at home, probably would have glued it, but I didn't. Wouldn't stop bleeding, no "urgent care" open, so I decided to head to the local ER in Cape May Courthouse for a few stitches. I hate over-utilizing healthcare resources, but really had no choice.


The ER billed Aetna 
99283 (level 3 emergency service) say, Yep, you need a few stitches $725.00.
I had a $200 copay, and Aetna paid $503.24
they also charged a 12013 (repair superficial wound) an additional $725.00 of which Aetna paid $703.24
along with some supplies for nominal charges paid about $50.

ALL total: Aetna paid $1,256.12 for my FIVE stitches and I paid $200. 
Total paid:  $1,456.12

NOW, I get a bill for the ER physician services who are NOT participating with Aetna, asking me for an additional $254.80 for the amount Aetna wrote off and didn't pay them.

No WONDER we are having so much trouble with the insurance companies trying to send everyone to the Urgent care centers. 


But not to be outdone, Michael:

Ah, c'mon Sue.  Your E.R. billing department must be staffed by amateurs if that's all they charged - I'd say that only deserves a "$#"  kidding me :)

When our son got a nice scalp laceration at night and we took him to the E.R. for staples, how's this for a "$#^!@&*^#)(&" kidding me:

E.R. "Emergency Service" charge - $1,906
E.R. "Surgery-Skin" charge - $1,235
E.R. "Supplies-Sterile" - $557 (I'm guessing this is for the stapler and two staples applied)
E.R. "Supplies-Non Sterile" - $160 (this must have been for the H20 flush to clean the wound prior to the staples)
Doctor "Emergency Service" - $284 (the only reasonable charge of the bunch)
Doctor "Surgery-Skin" - $533

So a grand total of almost $5,000 charged for ten minutes of history, exam, and anticipatory guidance,  some water flushed by a nurse (actually I think it might have been a nursing tech), and the doctor putting the staple gun against his scalp for 10 seconds to pop in two staples.   Since I knew this doctor and I hadn't seen him in awhile we probably spent more time catching up then was spent on medical care.

Obviously the insurance PPO discount got it down significantly.    I need to call the billing office on my day off and have some fun seeing how they justify such ludicrous charges.

The policy implications:

While these true stories are amazing on their face, I believe that they are emblematic of what the real problem is with high costs of health care in the US.  The problem is not overutilization, it is high prices, and creative billing by hospitals, and also some doctors.
When reforms to lower health care costs are proposed, a prime question needs to be: would the proposed reform attack those high prices?  Or is the proposed reform something that would diminish utilization more, make utilization “more efficient” (e.g., reduce duplicated tests), or put more burden for paying onto the patient?  If a reform doesn’t attack prices, it is slashing at a peripheral issue only.

Note also from Sue’s post the complicity of the insurance company.  Some say they should be our agents to keep costs down.  But high prices in one sector leads to high prices in another.  If the insurance company has a set margin and it pays out more for care, it raises its premiums so it can collect more, and its profit will be a percentage of that higher number.   As a result, the insurance company and its executives make more money.  This phenomenon, then it collects more in premiums, and the companies and the executives make more.
This is precisely what happened in the auto industry, as UAW and management scratched each other’s back.  Only competition from abroad brought changed that situation.  Bring on more Indian radiologists on call at night!
budd shenkin

Sunday, February 16, 2014

On National Guidelines and Recommendations

My pen pal on the SOAPM (Section on Administration and Practice Management for the American Academy of Pediatrics), Peter Pogacar, posted this article about the recent de-recommendation of mammograms:

This article tells of misadventures of the author’s mother in getting her mammograms, being led astray and confused by findings and doctors and a system that were confused, scattered, uncompassionate, and not patient-centered.  She also talks about being distrustful of doctors because something similar happened to her when her son had a rare condition and the doctors were unsure and, it seems, disorganized. 
This raises a general question: can blanket recommendations – “guidelines” -- really work?
I have a friend who does mammograms as his almost exclusive province of work.  He is skilled and very sensitive to people and patients, and very careful.  The situation of vagueness, misdiagnoses, lost in the system, I'll call you in the next week or so to tell you whether you will live or die -- none of this would apply to my friend Jonny's patients.
So, because the national "average" is poor -- there are lots and lots of doctors and services that suck, we know -- does that mean that one should not get mammograms at Jonny's office?
This is the problem with general guidelines.
Take the case of PSA tests.  They are recommended against for many of the same reasons as mammograms.  But I have a urologist friend Joel.  I have full confidence that if my PSA rose -- it hasn't, thank you God-- but if it did, Joel and I would figure out what to do.  If I had higher anxiety, so be it.  I don't believe in willful ignorance.  Just because a busy and insensitive and perhaps a rather stupid and crass doctor somewhere else (many are, unfortunately) couldn't handle it, does that mean Joel and I shouldn't get this test?
Or take the new guidelines for statins and the treatment of lipid disorders.  My friend Steve is a lipidologist; that's pretty much all he does these days, because he likes to specialize.  He is livid about the new recommendations, as are many.  He gets personal -- the head of the committee is a Doctor Stone, and Steve tells me that people in his department in Chicago, I think it is, refer to him as "Pebbles."  Steve says the recommendations are so un-nuanced that they are virtually worthless.  Much of it looks at the "evidence-base," to the exclusion, Steve says, of reasoned clinical judgement.  Just because something hasn't been "thoroughly studied" doesn't mean you can't make judgements.  Maybe some issues are just too complex to have a national guideline.  Maybe some things really need to be looked at individually by good doctors.  It's too bad there are bad doctors out there who will do unreasonable things.  It's too bad that some drugs will be taken by millions of people and cost a lot.  But does that really apply to the individual situation?
Finally, take me.  I think I'm a pretty smart guy at times.  Years ago the Hepatitis A vaccine made its entrance to our scene.  I thought, great!  Now people can go to Mexico and eat oysters without getting a 5cc shot in the butt every few months.  But no!  "National guidelines" said that "everyone should not get this vaccine."  It was not "cost effective."  Hepatitis A "was not a lethal disease."

Well, not cost effective for whom?  I had well-off patients, and I was well off enough that $100 was OK to spend to avoid getting yellow and shrinking up and laying dormant for six months.  Just because every public agency in the country and some insurance companies didn't want to pony up the money didn't mean that in individual cases it didn't make sense.  Then they found that the incidence of disease in California was high enough to recommend it.  Then they decided to recommend it nationally.  Hell, it made sense to begin with!
And then we need to remember this: "guidelines" are issued by committees, people who get together, disagree, and finally come to on agreement with a statement that does not include the minority opinions of the group, nor the members of the group who quit in disgust at what was going on (this happened to the lipid group.)  These are compromise documents that suppress minority opinions.  Most breakthroughs and smart thoughts are at first minority opinions, often minority opinions of one.
So, pardon me if I take national recommendations with a couple of teaspoonfuls of salt.  I'm finding a good doctor, and I'm talking to him personally, I'm demanding good care, and the females in my family are going to avoid dying of breast cancer if it's at all possible.

Budd Shenkin


Friday, January 3, 2014

Obamacare and HDHP's -- Reality Bites

In my never-ending quest to produce an oped type article that could get published, I have come up with the following.  When will lightning strike?

On the other hand, I have to admit I don't put much effort into getting my works published -- I send them out to one or two papers and then go back to writing something else. 

Reminds me of the guy who prayed to God to win the lottery.  Amazingly, God appeared.  He said, "Manny, this is your lucky day.  I am God, and I will grant your wish.  I understand you have been a careful man, and you haven't taken many chances in life.  I have heard your wish, and Manny, because you have been respectful and careful, I will grant your wish."  And with that, he disappears.

Overjoyed, Manny then waits for the call from the lottery people day after day.  But nothing appears, no call, no letter.  So Manny prays again, and says, "God, why have you abandoned me?  I have been a careful man, a respectful man.  I believed in what you promised me.  Why, God, why?"

Once again, God appears to him, and Manny renews his plea.

God looks sternly at Manny, and says, "Manny, it is true I am a jealous God and a vengeful God.  But Manny, I am also a just God, and I keep my promises.  Manny, will you work with me here?  Buy a ticket!"

Well, enough of merriment.  Here is my new oped.  One of these days I'll get it right.

Now that the ACA is here, many people are being faced with the stark reality of the health insurance plans on offer.  That reality in many instances is called the High Deductible Health Plan (HDHP).  The most reasonable reaction is: is that all they could come up with?

We are told that HDHPs are necessary to make the insurance policies “affordable,” which they barely are.  HDHPs mean that the subscriber pays the premium, a co-pay for each medical visit, and then pays fully out of pocket for everything except preventive visits and tests up to the deductible, which is typically $5,000 or more.  One may ask, by what definition is this “affordable?”

Defenders say that these policies are so expensive because of the high cost of health care.  No kidding.  That’s the definition of a circular argument, it is expensive because it is expensive.

In fact, HDHPs are themselves evidence of the failure of cost control.  The high cost centers of medical care are generally in the hospitals, in specialist procedures, in extensive testing, in medications, and in end of life care.  It used to be thought that utilization was the problem, that too much was done to and for patients.  Increasingly, however, we realize that the real problem lies in the prices.  The United States far outstrips other countries in the price of procedures, drugs, and hospitalizations.

But as we know, one person’s cost is another person’s or institution’s income.  Those with high incomes are called vested interests, and every vested interest will defend itself.  When the ACA was being negotiated, the health care reformers hoped to extend insurance coverage and contain costs.  In the end they had to settle for only extending coverage as health insurance companies, hospitals, pharma, and high-income specialists defended themselves very well.

Who won’t do well under the ACA?  While many more patients will be “covered,” it is clear that ordinary outpatient health care still will be hard to afford for many.  Likewise, while the large institutions will probably prosper, your local primary care practitioner will feel the bite as insurance companies strive to reduce those payments, and patients try to economize even more on visits to the doctor.

In fact, HDHPs are terrible medicine for the health care system to take.  These policies restrict primary care, when the country needs more primary care, not less.  Even fewer graduating doctors will choose primary care as careers when that is the main target for economizing.  Quality of care will be reduced as many diagnoses of serious disease will be made later rather than sooner, because patients will be thinking twice or three times before visiting the doctor.  The burden of disease will not be dispersed among all the insured under HDHPs – if you or your child have a chronic illness, you will be paying up to the deductible every year.  In other words, instead of relief, the sick get another burden placed upon them.

Moreover, HDHPs violate exactly the group that President Obama has vowed to protect.  If you have a sick child and you are on Medicaid, you will visit the doctor at no cost to yourself.  If you are financially well off, the deductible and co-payment will not be an obstacle, you will visit the doctor.  But if you are in the just-making-it class, if you have a job but not much left over to save, and if you have a sick child, then you will have to think, “Is my child $100 sick, plus tests?”

HDHPs are terrible health policy.  There are plenty of alternative solutions that actually do save money on the expensive areas of care, and maybe the pressure of the ACA will deliver us to those solutions in time, despite the objections of vested interests.  One can only hope.  In the meanwhile, pardon us if we look at the HDHPs on offer and say, “Is this the best that they could do?”

Budd N. Shenkin, MD, MAPA

Obamacare Confusion - A Note From The Field

Three years preparation time was apparently insufficient for governmental agencies and health insurance companies to prepare for a transition.  What a combination!

Here is a result reported by a colleague from Texas:

Just received a transfer request from family of 2 long-time patients.  Parents went to exchange to get insurance.  They made sure that we were on the plan they chose (a BCBS HMO).  They just got their new cards and called to reconfirm that we are on the plan, but we are not (BCBS HMO Advantage). 
There may have been a language barrier, as the family is primarily Spanish speaking. 

Both kids have chronic health care issues and I have spent many many hours helping them to coordinate care and treat them. 

They were told they can change their plan in a year. 

This saddens me greatly.  I'll be reporting it to the appropriate people at the state and county level who are monitoring these issues. 
I fear this is just the tip of the iceberg regarding to confusion as to what exactly people are signing up for.

Budd Shenkin

Thursday, December 26, 2013

The Images of Children

--> It is a truism that we learn a lot from our children, in so many different ways.  Most directly and memorably, we are told what is wrong with us.  It’s often accurate, both what we do wrong in the general world (“don’t tell her that!”); what bad drivers we are (not true in my case, actually); and at times amusingly and at times tragically, our failings as parents.  As Adam Gopnik wryly observes, parents should hope to receive from their children, an probably deserve, are pity and tolerance.

Then, we learn a little more subtly and indirectly.  In the act of being parents we learn about our own parents, and ourselves as the children we were.  We deal with our children’s temperaments and learn about our own.  For some of the kids we have had to give notice, “We are going to leave in ten minutes, so get ready,” because they need that time to prepare themselves.  This is because they perseverate, which means they persevere in what they are doing and have trouble cutting it off.  Then I noticed that this is true of me.  Without thinking about it, I think, my wife Ann has learned to say the same thing to me – she just did it two nights ago! -- “We have to go in about ten minutes.”  3 ½ year old Lola and I need the same warning. 

Even more subtly, perhaps, we can see how they see the world, and then realize how we ourselves used to see the world, and how we probably still see it, but that view is hidden behind a veil of verbal and conceptual constructs that we have learned to use.  Which brings me back to Lola. 

(Just an editorial note: Ann has warned me for my own good that I should watch how much I talk to people about Lola.  It’s OK to talk to her, Ann, about Lola, because she is her grandmother.  My friend Adele said that I can fire away about Lola to her, for which I am grateful.  Now I have to decide, how much can Lola be in the blog?  Here’s my thinking – the big problem with talking about grandchildren is the captive-audience problem.  So, are you the reader a captive audience?  I’m figuring not.  So here goes.)

Lola is very verbal and active – very – so we get to see what she sees and think what she thinks.  Three days ago she was watching Barney, and pretty soon Lola, Ann and I were marching around the coffee table in a “numbers parade,” Lola with a big number 1, Ann with 3, and me with 7, going round and round just like on Barney.  Then the problem popped up – we were in a circle, and Lola likes to be first, “I want to win!”  It’s hard to be first in a circle, so Lola kept catching up to Ann and passing her impatiently, and then me.  It was thus that Lola discovered the psychodynamics of the circle.  (Ann, meanwhile, being a self-conscious sort, perhaps another element of temperament, kept looking out of the windows to make sure no one was watching what was going on in our house.) 

Lola has always been like this, determined.  It has become both determined to achieve, and determined to win.  It’s ingrained.  She’s an only child, no competitors at her level, so she has to beat us – which she does.  It’s just a human variation.

That’s temperament.  Now, view of what goes on around you.  Sometimes, what we see as a means she sees as an end, our process is her prime result.  As an only child, she comes to us to play, so instead of our seeing her play with others, we get involved directly.  A few months ago, she turned to us and said, “Let’s make a list!”

That was a little bit startling – what was she after, going to the grocery store, or what?

“A list of what,” we asked. 

“Hmmm,” she said.  “Let’s see.”

Making the list was the thing.

The same thing happened a few days later.  She was looking around to do something, turned to us and said, “Let’s have a meeting!”

“A meeting for what?” we said.

“A meeting!” she said.

“How do we have a meeting?”

That was easy: she sat us down at the dining room table, took some minutes to arrange various bowls and candles on the table, had me sit at the head on her right side, and sat Ann to her left.  We looked at each other, sat a while, wondered if we should make a list, and then, attention span for 3 ½ year olds being what it is, the meeting was over.  Mission accomplished.  If you think about it, it was probably not much different from most meetings in business, certainly in a hospital from my experience. 

When we were in Hawaii last month she kept bugging us to “make a hotel.”  I didn’t know what that was, exactly – was it arranging the cushions from the couch in the TV room so that there was a little cave underneath, and calling it a hotel, the way we made a castle last visit?  We avoided her making-a-hotel project until she brought it up for maybe the fifth time.  “OK,” I said, “Let’s make a hotel.”

She got to work in the TV room.  First, it turned out, we needed a front desk.  Turning over the magazine basket provided that.  Then the front desk needed a computer – pieces of a wooden puzzle in primary colors served well.  Then we needed rooms.  I was sent to retrieve her sleeping bag and put it on the floor in front of the TV, and I had my room.  I forget what it was that was the closet.  I lay down in my room, and then tried to position myself so I could actually see the TV.  “No, Baba, you need to stay in your room!” she said.

So while I was resting in my room, she became The Front Desk Girl, sitting up alertly and expectantly for any arriving guests.  Truthfully, she was more professional than many who actually fill that role.  So we had our hotel, however abstract and minimalist it might have been.  We stayed in character for a few minutes, and then I heard, “Baba, the Front Desk Girl is getting tired.”  Mission accomplished, it was out to the pool again.

Then when we got home to Berkeley, Lola wanted to play “Hawaii.”  What could that be?  I had no idea.  So in her bedroom at our house we set out to play “Hawaii.”  As before, La Lolls, as I call her, was the construction chief.

“First, we need some palm trees!”  I actually forget what we got to make the palm trees, but there were two of them by the window in her room.

“Now, we need a roof.”

A roof?  What was she getting at?  We got a blanket to top of the two posts at the foot of the bed.

Then we were ready to eat, apparently.  I was sent for a bowl of Cheerios, and then we were having breakfast on the bed, under the canopy (or nearly so), and with two palm trees by the window. 

Then I realized what the story was.  In the morning at our house in Hawaii, I go get the papers, someone makes coffee, and we go out to sit on the lanai under the roof what we call the pavilion, and have breakfast.  It’s an absolutely favorite part of the day.  Lola then gets her bathing suit on and gets into the pool in the morning sunlight.  Easily recreated in her sunny bedroom in Berkeley.

Finally, Lola as shop girl.  Last year and this we have gone into the City and Sara and Ann leave Lola and me together as they go to Christmas shop.  We go upstairs in Bloomingdale’s.  We look at the mannequins and imitate them, arms akimbo, eyes vacantly on the ceiling.  Lola crawls on the highly polished floors, investigates the fake snow around the mannequins, crawls and pants like a dog.  OK, the commercial motivation is what we think of, but look at it from her point of view.  It’s basically art.  Imaginative clothes to wear, lots of enthusiasm from staff and shoppers, looking this way and that, everyone dressed up, the floors of the wide aisles waxed and cleaned beautifully.  It’s art, it’s a vision, it’s an experience.  Besides being a dog on the floor panting with tongue out, which is fun, what Lola wants to be is a shop girl. 

Last week on Bloomingdale’s third floor in a relatively deserted department with an older lady named Lucy, from Boston originally, I bought Ann a sweater.  Lola then helped Lucy by finding a big brown bag in one of the drawers, and then unwinding about 20 feet of green ribbon behind the desk.  She then swiped the charge card and pressed several buttons on the computer.  Lucy just doted, bemoaning the fact that she had only sons, and called to a young colleague walking by, “She wants to be in retail!”

I started out saying we learn from our kids.  One thing is how to have fun!  My friend Herschel says, “You’re never too old to have a happy childhood.”  I do it vicariously with La Lolls, and Herschel does it vicariously by riding roller coasters – I say vicariously, because I have to think he is enjoying giving such fun to his inner child.

But another thing is looking at how Lola appreciates things.  It is in images.  The hotel desk and computer, the palm trees, the roof of the pavilion.  It’s images.  We live an analog life, no matter how much digital technology we employ to get there, the end result is analog, because that’s how we appreciate it.

Also, just as it was inborn in Lola to be an achiever and a participator, it is inborn in her to indulge in the abstract.  Look at those images and what they were represented by.  We are born abstract artists.

These images of Lola remind me of dreams.  We dream in analog images, sometimes incomplete.  Later in life, if she has a palm tree dream, it will be about her happy life when she was three.  Or about her mommy and grandparents and feeling safe and happy.  It will all be contained in her image of a palm tree.

Budd Shenkin