It wasn’t the prospect of a hanging that did it in my case. For me, my mind was concentrated by my being interviewed for KALW by a very intelligent journalist on the subject of primary care. I’ve always said, if you can’t explain something so that an intelligent layman can understand it, you probably don’t understand it enough yourself. I don’t know how it will be for the listeners, but for me it was a very good educational experience. It clarified my thinking.
Being me, I found the interview an opportunity to disagree with all three of the other interviewees for this project, all of whom I know and like: Tom Bodenheimer, MD, of UCSF internal medicine; Kevin Grumbach, MD, of UCSF family practice, and Richard Scheffler, PhD, of UCB School of Public Health. Interestingly, I found myself to the traditional Right of the two academic docs, and skeptical of Richard’s traditional economics view of medical care, although let me say, not dismissive of any of them. They are all smart and thoughtful and worthy on all levels.
Tom has published great articles on the plight of primary care, and accurately focused on money as the biggest problem. Some people say primary care is too difficult to do, not professionally rewarding enough as compared to specialities, etc. Tom doesn’t buy this and neither do I, and neither does Kevin for that matter. For a person-oriented physician, noth other specialty provides the long term relationships of primary care. But faced with the prospect of primary care for $120-$190K a year, vs. anesthesiology for $600K a year – is this a choice? Not to mention cardiology, ENT, ortho, various surgical specialties, etc. You don’t have to be an economist to figure this one out. But my interviewer said, do primary care doctors need more money, or as Tom Bodenheimer says, are the primaries getting enough, it’s the specialists that need to get less, so the choice of a medical student is less economically based?
Time to disagree with Tom. I’m reminded of one of Martin Amis’s books on Russia, when the young people are parading around saying, No One Should Be Rich! An old lady says, I remember when we said, No One Should Be Poor!
Tom (and Kevin) represents a strand of medicine that I call the missionary strand. We do have a priestly role, but I personally have no desire to wear a hair shirt, and neither do most doctors. I don’t ask for poverty, I ask for an even playing field. It’s true that doctors in the US make more than in other countries, but that’s not true of primary care docs. If all doctors were to make less money, medicine would be less attractive to the elite, and I’m for as many smart and aggressive and entrepreneurial and progressive and inventive minds as possible in medicine. Economics works.
My interviewer said, but given more money, would the doctors just bank it? I said, to some extent, but then what we see now is primary care doctors with insufficient resources to bulk up the office with nurses and other personnel – we train the staff, then they leave for hospitals and specialists offices, where the money is. We are asked to be a medical home, calling patients on the phone to see how they are doing, and directing patients and spending more and more resources for patients, but to do this we need more money to spend. It has to stop all going to hospitals and specialists – but I guess I’ve mentioned that.
Would primaries do that, spend some money on the practice as well as bank some of it? They would if there were a fair market. Patients appreciate these aspects of care, they aren’t hidden as are some aspects of quality. So patients would choose to visit the doctors who had beefed up their offices with the enhanced payments they receive. In this case, the market would work.
Kevin says that hankering for the past security of your friendly neighborhood doctor is passé. He says that much of primary care can be accomplished by midlevels (nurse practitioners and physicians’ assistants), nurses, and others, so we should husband our physician resources and save money and be more efficient by having independent nurse clinics and much more clinical work done by others than doctors. I disagree.
First of all, the problem of medical cost does not stem from primary care, it stems from the money pit of hospitals and specialist services, and IMHO it is more a price problem than a volume problem. So you’re going to fix a money problem occurring elsewhere by economizing in primary care? I think this is a very poor solution. Since I tend to be sometimes belligerent, I say – Don’t give in to those schmucks!
At Bayside we have NP’s and PA’s and we love and respect them, definitely. My own step-daughter often chooses to go to a PA for her own care. But our PA’s often go over to our lead FP MD and ask him questions, seek assistance and direction, etc. They are not doctors, and they don’t think they are.
What is it that makes me value a doctor so much? Is it because I am one? I don’t think so. Mid-levels do well on measurable quality parameters, but quality assessment is still rather rudimentary. The deeper considerations a doctor makes, the questing after difficult diagnoses, the balancing of judgment calls – doctors weren’t highly selected and highly trained for nothing.
Kevin is right that we need to beef up our offices with personnel other than physicians – the medical home is a good and important concept. But he needs to be a little less enthusiastic in calling for a substituting for primary care doctors and economizing. In our country we should be able to afford primary care doctors, and we should be able to afford a first-class primary care system.
Kevin also seems to represent a potent line of thought that the Obama Administration has mindlessly adopted – that we need to have larger systems of care – Kaisers and other large entities – and primary care needs to get out of the communities and into the large organizations. I couldn’t disagree more. The local doctor’s office is personal, and the best doctors in these offices care for their patients, and moreover, care about their patients in a way that an employee of a large organization just won’t. Sorry, they won’t. And anything that a primary can do in a large organization with quality enhancement, we can do in our local offices. I personally think the offices need to be larger than just one office, but the best offices can do it even with three or four docs. They just can.
An example of caring: my friend Bob Shimizu is a long time pediatrician at Lamorinda Pediatrics in Lafayette. He recently cut back his hours markedly and feels much more relaxed. I asked him what the big difference was. He said, “The worrying. I would get so worried about some of my patients. That was really getting me down.” Worrying outside the office. Caring about his patients, not just caring for his patients. Think that’s happening at Kaiser? Betcha not.
Richard had not yet been interviewed so whom I couldn’t comment on what he had said. But I had read his interesting book, Is There a Doctor in the House, and my interviewer was sharp enough to anticipate some of what he would say –do you agree with Scheffler that it is all right to have to wait to see a doctor?
My answer is no. In this respect, medicine is not like other goods and services. It is OK to wait for cable installation, but it is not OK to wait to be evaluated for sudden feelings of weakness and arm pain that could be musculo-skeletal, or could be heart. Urgent care and ER care are not substitutes for good primary care by your own doctor whom you know, and who care about you and you know cares about you, and who is good and competent, and you know is good and competent. There is no substitute, and waiting is not OK. As I said, I like and respect Richard, but his strength is also his weakness, which is that he is an economist. Waiting might be fine in economics because it is cost sparing, but add into early detection the issue of patient anxiety, and you have to be better staffed than what is envisioned by economics. Plus, it’s all because of the horrendous rents paid to monopolistic systems of care at the hospital and specialist levels that we even contemplate savings in primary care, which is so inexpensive by comparison.
I loved being under the pressure of this interview, but typical of me, I found a way to disagree with everyone else on the panel. But hey – I still think I’m right. Don’t you?
Budd Shenkin
Sunday, August 29, 2010
Thursday, August 26, 2010
Carpe Diem
In pediatrics there is a syndrome called the “vulnerable child.” This occurs when a child has a severe illness, such as prematurity, a severe accident, a severe event. Parents are scared out of their wits, and when the child recovers they wonder,, is he OK? Was damage done that isn’t apparent? Supernaturally, is there some fatality at work that will emerge later, a tainted future?
When I was just starting in practice I covered for a colleague on his day off. I saw a teenage boy, big and strapping, six feet tall and muscled, probably played on his football team. I examined him and told his worried mother, “He looks OK. Nothing serious.”
She said, “Are you sure?” Pause. “Doctor, he was a premie, you know.”
Luckily, I knew about Vulnerable Child Syndrome. I had to laugh, and told her that her fears were understandable, because she had been through a trauma that left her considering her football player as somehow vulnerable. I said, “But look at him! Don’t worry.”
In our house we have our own vulnerable child. Peter had his birthday yesterday. The little tyke is now 27 and a third year law student. He was a premie himself, 35 weeks, five pounds seven ounces, while his mother had HELPP Syndrome, which was then a month or two short of being described in the literature, which left us to fend for ourselves in diagnosis. She presented with a nose-bleed that wouldn’t stop because her blood was coagulating within her veins. Luckily she went into labor and had Peter – in those days a trained nurse or technician didn’t attend every delivery, and it was left to me as the father to resuscitate Peter, which I did, but he was in the hospital for over a week, I guess, looked like a drowned rat, and Ann had a bone marrow aspiration and clotting tests for days in the ICU as she recovered, which she did, since pregnancy is the cause of HELPP.
Then at age two Pete needed heart surgery to close a hole, called an ASD. But not before the insurance company tried to revoke our policy, on the grounds that we failed to reveal when we got the policy that Pete might need surgery, which of course we didn’t know. This insurance company practice, called rescission, was just outlawed by ACA (Obamacare). That operation went well. He was up and in the halls saying “Pitch to me!” just a few days later, amazingly, on the same floor that I had done my residency on.
Then at the beginning of his junior year of high school Pete was on a camping trip to foster class solidarity. In the middle of the night a 4,500 pound tree fell in the midst of the sleeping group and Pete was only saved because, to the amusement and derision of his classmates, he had brought a very puffy air mattress along with him – he apparently shares his mother’s and father’s attitude to roughing it. The tree fell right on him, but the air mattress cushioned the blow enough that he escaped with losing a kidney, 18 inches of small bowel, five broken transverse processes of his lumbar spine, a broken wrist, and no trauma to the spinal cord. It was weeks and months of recovery, and the scars of the heart surgery and the tree trauma now form an anterior zipper line from neck to pelvis, almost. You can imagine the trauma his parents endured as well, with the 4:30 AM phone call of your son is in critical condition, and the days afterward.
Pete now has a truly existential view of life. He knows that we all die, and that we could do so at any moment. He is not afraid, but carpe diem is definitely for Peter.
And so it was that we received word yesterday of how Peter celebrated his birthday. Peter went sky diving from 18,000 feet and loved it.
He told his parents afterward. That was thoughtful of him.
Budd Shenkin
When I was just starting in practice I covered for a colleague on his day off. I saw a teenage boy, big and strapping, six feet tall and muscled, probably played on his football team. I examined him and told his worried mother, “He looks OK. Nothing serious.”
She said, “Are you sure?” Pause. “Doctor, he was a premie, you know.”
Luckily, I knew about Vulnerable Child Syndrome. I had to laugh, and told her that her fears were understandable, because she had been through a trauma that left her considering her football player as somehow vulnerable. I said, “But look at him! Don’t worry.”
In our house we have our own vulnerable child. Peter had his birthday yesterday. The little tyke is now 27 and a third year law student. He was a premie himself, 35 weeks, five pounds seven ounces, while his mother had HELPP Syndrome, which was then a month or two short of being described in the literature, which left us to fend for ourselves in diagnosis. She presented with a nose-bleed that wouldn’t stop because her blood was coagulating within her veins. Luckily she went into labor and had Peter – in those days a trained nurse or technician didn’t attend every delivery, and it was left to me as the father to resuscitate Peter, which I did, but he was in the hospital for over a week, I guess, looked like a drowned rat, and Ann had a bone marrow aspiration and clotting tests for days in the ICU as she recovered, which she did, since pregnancy is the cause of HELPP.
Then at age two Pete needed heart surgery to close a hole, called an ASD. But not before the insurance company tried to revoke our policy, on the grounds that we failed to reveal when we got the policy that Pete might need surgery, which of course we didn’t know. This insurance company practice, called rescission, was just outlawed by ACA (Obamacare). That operation went well. He was up and in the halls saying “Pitch to me!” just a few days later, amazingly, on the same floor that I had done my residency on.
Then at the beginning of his junior year of high school Pete was on a camping trip to foster class solidarity. In the middle of the night a 4,500 pound tree fell in the midst of the sleeping group and Pete was only saved because, to the amusement and derision of his classmates, he had brought a very puffy air mattress along with him – he apparently shares his mother’s and father’s attitude to roughing it. The tree fell right on him, but the air mattress cushioned the blow enough that he escaped with losing a kidney, 18 inches of small bowel, five broken transverse processes of his lumbar spine, a broken wrist, and no trauma to the spinal cord. It was weeks and months of recovery, and the scars of the heart surgery and the tree trauma now form an anterior zipper line from neck to pelvis, almost. You can imagine the trauma his parents endured as well, with the 4:30 AM phone call of your son is in critical condition, and the days afterward.
Pete now has a truly existential view of life. He knows that we all die, and that we could do so at any moment. He is not afraid, but carpe diem is definitely for Peter.
And so it was that we received word yesterday of how Peter celebrated his birthday. Peter went sky diving from 18,000 feet and loved it.
He told his parents afterward. That was thoughtful of him.
Budd Shenkin
Tuesday, August 24, 2010
The Week of an Administrative Physician
Last week I went to our Dublin administrative office to console our staff about the sudden death over the weekend of our 32 year old beloved co-worker Preneet; conducted three clinician office meetings on Monday, Tuesday, and Wednesday; saw patients; delivered a eulogy at Praneet's funeral before 400 attendees; interviewed a candidate for Administrator; visited the Berkeley office and consulted with our lead FP there about our office direction and his staffing problems; conducted our weekly business office meeting, while signing checks and reviewing our final contract offer to our Administrator candidate, and contacting the CEO of Children’s Hospital about poor care in the ER and trying to schedule a meeting with him; attended the Children First IPA Board meeting; consulted withe the CEO of San Ramon Regional Medical Center about a new office for us and recent movements of other doctors in the area; gave a day long deposition on a totally bogus wrongful termination and assault and battery lawsuit brought by a wretched former employee; consulted with experts, lawyers, another clinician, our HR Manager and an office manager about what to do with a physician who was possibly impaired; contacted our probably not impaired clinician and worked our way through our course of action; had a radio interview on the subject of primary care; and prepared for a meeting the following week with a physician who was not meeting expectations in various behaviors and documentation. Among other things.
Then over the weekend I asked our scheduler for rounds and call, the beloved Tina Hong, MD, my co-author on a recent Pediatric Puzzler in Contemporary Pediatrics, to do a little rescheduling of rounds and call to account for the temporary absence of our also beloved possibly probably not impaired physician, which she expertly and happily did. So Tina said, “Where have you been, on a cruise? I haven’t seen you!”
Such is the work of administration.
I had to laugh.
Then over the weekend I asked our scheduler for rounds and call, the beloved Tina Hong, MD, my co-author on a recent Pediatric Puzzler in Contemporary Pediatrics, to do a little rescheduling of rounds and call to account for the temporary absence of our also beloved possibly probably not impaired physician, which she expertly and happily did. So Tina said, “Where have you been, on a cruise? I haven’t seen you!”
Such is the work of administration.
I had to laugh.
Sunday, August 15, 2010
What's It Gonna Take?
I was on vacation the last two weeks of July, cruising. When we cruise, we read. My first book was City of Thieves by David Benioff. During the 900 day Siege of Leningrad two young men have adventures, including an encounter with cannibalism (true), in searching for a dozen eggs. Good book, excellent even. Recommended.
But the big book I read was Winston’s War by Max Hastings, obviously about WW II and Churchill, from his accession to Prime Minister to his electoral defeat during the Potsdam conference. Hastings says, btw, that the defeat was warranted – not rejecting his wartime leadership, far from it, but with the war just about over the focus would be on domestic policy, and Churchill had scant interest in domestic issues, and what interest he had was retrogressive. This is not hagiography, but lots of warts as seen by others, and with full range of the doubts of people of the time, large and small people and doubts.
What struck me very forcefully, although I knew it before, was how Americans and the British for years denied the existence of the Nazi threat, or minimized it, or in the case of the British upper class, sympathized with it. It took so long for people to come to terms with it! In retrospect it is so obvious. It’s not in this book, but if the Allies had only stopped the Germans from occupying and remilitarizing the Rhineland in 1934, the Nazis would have backed down and history would have been different. That’s fact, not surmise. From then on it was a progressive steamroller, Chamberlain’s famous dance of appeasement, and war without Western preparation.
Then the Americans – even with much of Eastern Europe, the Netherlands, Belgium and France occupied, even with Britain under siege, most people in the US thought they could and should keep out of it. Just amazing.
Yes, there were mitigating circumstances. Britain and France had lost a generation in WWI and were loathe to re-engage. Americans did not like nor admire the British. “Toffs,” they were regarded as. Poor fighters (with reason.) Enslavers of the Colonies. Plenty of reason not to like them. Plenty of reason not to admire the French military as well.
Who saw the necessity of opposing Hitler? In Britain, Churchill first and foremost. In the US, Roosevelt for sure. But leaders are not dictators and it took time for the countries to catch up, to see more and more clearly what they were up against. No one wanted to change what they were doing, no one wanted to think of war again. So they denied it.
Denial is an essential part of life. We generally don’t think much about our own mortality, a kind of denial. If you look at yourself and think about it, right now, I bet you can think of things you are denying right now. Just not thinking about it, and going on as if it didn’t exist. It allows you to be functional. But sometimes it’s not a good idea.
In the case of WW II, it took Pearl Harbor for America to stop denying. That did the job pretty well. We still don’t know what would have happened with Europe if Hitler hadn’t declared war on us later that week. But he did and denial was over.
I do recommend this fine book. As a journalist, Hastings is able to take us back in time so vividly, to abolish knowledge of the ending just for a little, and see what the atmosphere really was at the time. He shows us that retrospective clarity is an illusion.
How does this apply to the present? We all know Santayana’s comment that those who don’t know history are doomed to repeat it. That’s essentially a hopeful statement, implying an ability to form the future through reasoned action. But it’s also possible that those who do know history are just as doomed to repeat it as those who don’t. In John Steinbeck’s redo of the Arthurian legend (another book recommendation from Budd) Merlin is asked: “If you can know the future, why didn’t you look ahead and see that this woman would be the death of you?” Merlin replies, “Oh, yes, I can foresee it, but that doesn’t mean I can avoid it.” Makes sense to me.
So here’s the question: Given the power of denial, what’s the biggest issue we are not facing now? What is the equivalent of the brewing Nazi and Japanese crisis of the 1930’s?
Islamic terror? Nah. We are spending huge time and money on it, but it’s really just an annoyance – what can they really do, how many of them are there really? It’s mostly drama. Even if they got a WMD. Even if Iran went nuclear.
Islamic expansionism? Maybe – look at France and especially the Netherlands. Look at how Islam took Kosovo from the Serbs by sheer procreation of the Albanian-Islamic minority become majority. But while a problem, it will be handled more or less, and I don’t think that’s it.
Rising countries with non-democratic governments? Maybe. We used to like to think that liberal democracy was ascendant since the demise of Communism in the USSR and Eastern Europe. Certainly something to contend with – Fukayama’s “End of History” was ridiculous when it was published and is now risible. I love liberal democracy and the Bill of Rights, but that’s a product of our specific Western culture, and its ascendancy was based on our economic and organizational power, which will soon be matched. So, it’s a problem, and it’s true that most people are not conscious of it. But I don’t see it as an impending crisis, just a persistent challenge. Competitive coexistence is most likely.
No, my candidate for major pending crisis in denial, crisis in the same league as Nazi Germany and WW II, is the environment. It’s not an unknown issue, but neither was Nazism. It seems quite clear that overpopulation and industrialization are burning up our planet. Ever since we discovered all that fuel below the surface of the Earth we have been burning it up, and in the process burning ourselves up. We use some of it well, but the “externalities” (to use economist-speak for pollution and carbon dioxide accumulation) come back to bite us, as the lobster-pot we live in heats up, more and more obviously. It’s an impending crisis, but it just won’t explode in the next year or two, so it’s possible to deny it, especially if you are over 50, where the power lies.
I see the Nazi parallel. Hitler built the military month by month, people saw it, but most preferred to think one could reason with Herr Hitler, or thought he was pretty far away in space and/or time. Our decade of the aughts has gotten hotter and hotter, but what the hey! Maybe it’ll stop! Maybe it will be a good thing? Who cares what happens to Bangladesh and the Maldives? Not our problem, is it? Do we really want to change our habits and economy substantially? Or do we say, like St. Augustine, make me chaste, but not quite yet?
As in the 1930’s, the forces of inertia are still in control. Greed is in place – oil and coal interests pay “scientists” to deny global warming. They pay Congress not to tax carbon. Developing countries are also resistant. They say, why should the West have the good standard of living and not us? Politically, it’s a game of chicken. China and Brazil say, we’re going to make progress – why should you always be ahead of us? We say, hey, we’re already here, don’t you realize you will make it worse for all of us? Why are you burning coal? You are making it worse for all of us. It’s a game of chicken.
A gradual approach now, like rearming would have been in the 30’s, would be to hitch profits to moderating climate change, by government incentives. But governments are weak. Corporations and sovereign funds rule the world, and they make money by doing the same thing they have been doing, time after time. There is even an ideology that these entities should not be looking for the common good, that “the market” will take care of it, and technology will “appear.” These are arguments of convenience. We are dealing with economic externalities, and as I understand it, such effects by their very definition do not enter the market. So the ideological market argument is specious. We need strong governmental intervention, and not only are our governments weak, but populations are in denial.
No one really wants to change. Psychologically, it’s just denial. Morally, it’s selfishness of the current generation. Intellectually, it’s often just stupidity and ignorance of science. And as we look for leadership, George Packer tells us, don’t expect much from the Senate. Our institutions fail us just as much as the British ruling class and our own isolationists in the 30’s.
To be educated, to see the future to some extent, to know some steps we should be taking now, to see little happening, is to feel like Merlin.
So, I ask --What’s it gonna take? What will our Pearl Harbor be, or our invasion of Poland? Nobody knows. I don’t know. But if this really is the brewing crisis that is being denied, then it might take something dramatic.
The environment is not my field, so I can’t speculate intelligently about what it will take. Hunger and thirst, rising sea levels and tides? Maybe. Maybe even as the Earth gets more and more depleted of forests, would it be possible that the oxygen level in the air, at 21% for millions of years, would drop, and we would all be living as though we were high in the Andes and Himalayas?
This is as far as I can get. History allows us to reason by analogy, but it is never exact. I know we are denying something that is important, and if we prevented it, that would be better than fighting it later. And I think it’s the environment. And I think it will take something dramatic to move us. And I think there will be a lot of conflict, that it won’t be peaches and cream. I wonder what it will be.
Budd Shenkin
But the big book I read was Winston’s War by Max Hastings, obviously about WW II and Churchill, from his accession to Prime Minister to his electoral defeat during the Potsdam conference. Hastings says, btw, that the defeat was warranted – not rejecting his wartime leadership, far from it, but with the war just about over the focus would be on domestic policy, and Churchill had scant interest in domestic issues, and what interest he had was retrogressive. This is not hagiography, but lots of warts as seen by others, and with full range of the doubts of people of the time, large and small people and doubts.
What struck me very forcefully, although I knew it before, was how Americans and the British for years denied the existence of the Nazi threat, or minimized it, or in the case of the British upper class, sympathized with it. It took so long for people to come to terms with it! In retrospect it is so obvious. It’s not in this book, but if the Allies had only stopped the Germans from occupying and remilitarizing the Rhineland in 1934, the Nazis would have backed down and history would have been different. That’s fact, not surmise. From then on it was a progressive steamroller, Chamberlain’s famous dance of appeasement, and war without Western preparation.
Then the Americans – even with much of Eastern Europe, the Netherlands, Belgium and France occupied, even with Britain under siege, most people in the US thought they could and should keep out of it. Just amazing.
Yes, there were mitigating circumstances. Britain and France had lost a generation in WWI and were loathe to re-engage. Americans did not like nor admire the British. “Toffs,” they were regarded as. Poor fighters (with reason.) Enslavers of the Colonies. Plenty of reason not to like them. Plenty of reason not to admire the French military as well.
Who saw the necessity of opposing Hitler? In Britain, Churchill first and foremost. In the US, Roosevelt for sure. But leaders are not dictators and it took time for the countries to catch up, to see more and more clearly what they were up against. No one wanted to change what they were doing, no one wanted to think of war again. So they denied it.
Denial is an essential part of life. We generally don’t think much about our own mortality, a kind of denial. If you look at yourself and think about it, right now, I bet you can think of things you are denying right now. Just not thinking about it, and going on as if it didn’t exist. It allows you to be functional. But sometimes it’s not a good idea.
In the case of WW II, it took Pearl Harbor for America to stop denying. That did the job pretty well. We still don’t know what would have happened with Europe if Hitler hadn’t declared war on us later that week. But he did and denial was over.
I do recommend this fine book. As a journalist, Hastings is able to take us back in time so vividly, to abolish knowledge of the ending just for a little, and see what the atmosphere really was at the time. He shows us that retrospective clarity is an illusion.
How does this apply to the present? We all know Santayana’s comment that those who don’t know history are doomed to repeat it. That’s essentially a hopeful statement, implying an ability to form the future through reasoned action. But it’s also possible that those who do know history are just as doomed to repeat it as those who don’t. In John Steinbeck’s redo of the Arthurian legend (another book recommendation from Budd) Merlin is asked: “If you can know the future, why didn’t you look ahead and see that this woman would be the death of you?” Merlin replies, “Oh, yes, I can foresee it, but that doesn’t mean I can avoid it.” Makes sense to me.
So here’s the question: Given the power of denial, what’s the biggest issue we are not facing now? What is the equivalent of the brewing Nazi and Japanese crisis of the 1930’s?
Islamic terror? Nah. We are spending huge time and money on it, but it’s really just an annoyance – what can they really do, how many of them are there really? It’s mostly drama. Even if they got a WMD. Even if Iran went nuclear.
Islamic expansionism? Maybe – look at France and especially the Netherlands. Look at how Islam took Kosovo from the Serbs by sheer procreation of the Albanian-Islamic minority become majority. But while a problem, it will be handled more or less, and I don’t think that’s it.
Rising countries with non-democratic governments? Maybe. We used to like to think that liberal democracy was ascendant since the demise of Communism in the USSR and Eastern Europe. Certainly something to contend with – Fukayama’s “End of History” was ridiculous when it was published and is now risible. I love liberal democracy and the Bill of Rights, but that’s a product of our specific Western culture, and its ascendancy was based on our economic and organizational power, which will soon be matched. So, it’s a problem, and it’s true that most people are not conscious of it. But I don’t see it as an impending crisis, just a persistent challenge. Competitive coexistence is most likely.
No, my candidate for major pending crisis in denial, crisis in the same league as Nazi Germany and WW II, is the environment. It’s not an unknown issue, but neither was Nazism. It seems quite clear that overpopulation and industrialization are burning up our planet. Ever since we discovered all that fuel below the surface of the Earth we have been burning it up, and in the process burning ourselves up. We use some of it well, but the “externalities” (to use economist-speak for pollution and carbon dioxide accumulation) come back to bite us, as the lobster-pot we live in heats up, more and more obviously. It’s an impending crisis, but it just won’t explode in the next year or two, so it’s possible to deny it, especially if you are over 50, where the power lies.
I see the Nazi parallel. Hitler built the military month by month, people saw it, but most preferred to think one could reason with Herr Hitler, or thought he was pretty far away in space and/or time. Our decade of the aughts has gotten hotter and hotter, but what the hey! Maybe it’ll stop! Maybe it will be a good thing? Who cares what happens to Bangladesh and the Maldives? Not our problem, is it? Do we really want to change our habits and economy substantially? Or do we say, like St. Augustine, make me chaste, but not quite yet?
As in the 1930’s, the forces of inertia are still in control. Greed is in place – oil and coal interests pay “scientists” to deny global warming. They pay Congress not to tax carbon. Developing countries are also resistant. They say, why should the West have the good standard of living and not us? Politically, it’s a game of chicken. China and Brazil say, we’re going to make progress – why should you always be ahead of us? We say, hey, we’re already here, don’t you realize you will make it worse for all of us? Why are you burning coal? You are making it worse for all of us. It’s a game of chicken.
A gradual approach now, like rearming would have been in the 30’s, would be to hitch profits to moderating climate change, by government incentives. But governments are weak. Corporations and sovereign funds rule the world, and they make money by doing the same thing they have been doing, time after time. There is even an ideology that these entities should not be looking for the common good, that “the market” will take care of it, and technology will “appear.” These are arguments of convenience. We are dealing with economic externalities, and as I understand it, such effects by their very definition do not enter the market. So the ideological market argument is specious. We need strong governmental intervention, and not only are our governments weak, but populations are in denial.
No one really wants to change. Psychologically, it’s just denial. Morally, it’s selfishness of the current generation. Intellectually, it’s often just stupidity and ignorance of science. And as we look for leadership, George Packer tells us, don’t expect much from the Senate. Our institutions fail us just as much as the British ruling class and our own isolationists in the 30’s.
To be educated, to see the future to some extent, to know some steps we should be taking now, to see little happening, is to feel like Merlin.
So, I ask --What’s it gonna take? What will our Pearl Harbor be, or our invasion of Poland? Nobody knows. I don’t know. But if this really is the brewing crisis that is being denied, then it might take something dramatic.
The environment is not my field, so I can’t speculate intelligently about what it will take. Hunger and thirst, rising sea levels and tides? Maybe. Maybe even as the Earth gets more and more depleted of forests, would it be possible that the oxygen level in the air, at 21% for millions of years, would drop, and we would all be living as though we were high in the Andes and Himalayas?
This is as far as I can get. History allows us to reason by analogy, but it is never exact. I know we are denying something that is important, and if we prevented it, that would be better than fighting it later. And I think it’s the environment. And I think it will take something dramatic to move us. And I think there will be a lot of conflict, that it won’t be peaches and cream. I wonder what it will be.
Budd Shenkin
Saturday, August 14, 2010
ICU's, interesting cases, and Primary Care
Atul Gawande is a genius writer in my book, or rather in his books and articles. But, even though I think his mother was a pediatrician (in Ohio), he is still a Boston-based high powered endocrinologic surgical specialist. So, in his latest New Yorker article on the depredations of high powered specialities ICU care and end of life expense and torture, I think he steps on his lede.
In the article Gawande writes very approvingly about hospice care, and recounts the torture inadvertently administered by the ICU doctors to dying patients. At the very end of the article - every article he writes is more than worthwhile reading - he mentions a case where the primary care doc had kept in touch with the patient and with the prospect of ICU care the primary doc gets the patient turned off, then quietly exits stage left.
Hey, Atul! That's the whole ffing point!! It's primary care, man! It was also the point in your South Texas article of the best little medical money machine in Texas. Stop stepping on your lede.
He and the other New Yorker doctor-writer, Jerry Groopman, also generally quite well worth reading, especially on EMR's in the NEJM, come from the background of intellectual (I'm not using that word in a good sense here) pompous (also not in a good sense) Boston specialist doctors (also not in a good sense) on rounds saying, "Hmmm. A very interesting case indeed!" And then they trot off the the next. Some decades later, Groopman says, in the face of caring for his own medical needs - hey! There are people in there with these "interesting" diseases!
No s... Dick Tracy! There are others of us, who I can only think very often wound up in primary care, who from the very first said, "What are these guys doing?" Don't they realize they are dealing with people? Is this part of the God complex? So removed? Then they come back to see, post-seduction, what the game is really about.
For a great comment from a pediatrician turned health policy guy, and classmate and friend of my step-daughter Sara, see http://www.huffingtonpost.com/aaron-e-carroll/its-the-life-in-end-of-li_b_664152.html?ref=email_share.
While I'm on this rant, might as well take on the academic liberal primary care establishment who take the position that those who look nostalgically to the family doctor of the 50's are doomed to disappointment. They say, we can't do that in this day and age. We need to cut costs and be efficient! We need to have Nurse Practitioners, and they should be independent! We need clinics with teams for all our patients! And, btw, doctors are people, too, so they need a very definite work week so they can be with their family and have enjoyable lives - so that means they can't be tied down to patients, rounds, call, etc.! (Okay, that last one is unfair, but I'm leaving it in anyway.)
Well, as my old roommate from Caribou, Maine used to say, bulldiggy. With all the money going to the money pit of hospitals and anesthesiologists (starting at $600K around here) and cardiologists and ortho and imaging (many with millions each year), what we want to economize on is primary care? You've got to be out of your mind!! We're great, we are what's needed, and the system needs to be based on us! We are the biggest bargains in the medical care arena, and you want to cut us??? We love our PNP's - they are great - but they ain't doctors, buddy. We're going to direct all the doctors to be these same specialists who are causing all the ICU problems, those emotionally dead souls, or at least confused? Give me a break!
OK, I know, I shouldn't be on the fence so much, you should know where I stand. OK. Next post I'll take a stand.
Budd Shenkin
In the article Gawande writes very approvingly about hospice care, and recounts the torture inadvertently administered by the ICU doctors to dying patients. At the very end of the article - every article he writes is more than worthwhile reading - he mentions a case where the primary care doc had kept in touch with the patient and with the prospect of ICU care the primary doc gets the patient turned off, then quietly exits stage left.
Hey, Atul! That's the whole ffing point!! It's primary care, man! It was also the point in your South Texas article of the best little medical money machine in Texas. Stop stepping on your lede.
He and the other New Yorker doctor-writer, Jerry Groopman, also generally quite well worth reading, especially on EMR's in the NEJM, come from the background of intellectual (I'm not using that word in a good sense here) pompous (also not in a good sense) Boston specialist doctors (also not in a good sense) on rounds saying, "Hmmm. A very interesting case indeed!" And then they trot off the the next. Some decades later, Groopman says, in the face of caring for his own medical needs - hey! There are people in there with these "interesting" diseases!
No s... Dick Tracy! There are others of us, who I can only think very often wound up in primary care, who from the very first said, "What are these guys doing?" Don't they realize they are dealing with people? Is this part of the God complex? So removed? Then they come back to see, post-seduction, what the game is really about.
For a great comment from a pediatrician turned health policy guy, and classmate and friend of my step-daughter Sara, see http://www.huffingtonpost.com/aaron-e-carroll/its-the-life-in-end-of-li_b_664152.html?ref=email_share.
While I'm on this rant, might as well take on the academic liberal primary care establishment who take the position that those who look nostalgically to the family doctor of the 50's are doomed to disappointment. They say, we can't do that in this day and age. We need to cut costs and be efficient! We need to have Nurse Practitioners, and they should be independent! We need clinics with teams for all our patients! And, btw, doctors are people, too, so they need a very definite work week so they can be with their family and have enjoyable lives - so that means they can't be tied down to patients, rounds, call, etc.! (Okay, that last one is unfair, but I'm leaving it in anyway.)
Well, as my old roommate from Caribou, Maine used to say, bulldiggy. With all the money going to the money pit of hospitals and anesthesiologists (starting at $600K around here) and cardiologists and ortho and imaging (many with millions each year), what we want to economize on is primary care? You've got to be out of your mind!! We're great, we are what's needed, and the system needs to be based on us! We are the biggest bargains in the medical care arena, and you want to cut us??? We love our PNP's - they are great - but they ain't doctors, buddy. We're going to direct all the doctors to be these same specialists who are causing all the ICU problems, those emotionally dead souls, or at least confused? Give me a break!
OK, I know, I shouldn't be on the fence so much, you should know where I stand. OK. Next post I'll take a stand.
Budd Shenkin
Sunday, August 8, 2010
Turkey and Anti-Semitism - It Could be Scary
I’ve never been one to spot anti-Semitism near and far. Nor to overlook it.
I was raised a secular Jew and remain one, married twice, each time to a shiksa, and my kids view themselves as half-Jewish, which you can be if Judaism is a nationality and a cultural heritage rather than a religion. I try to be dispassionate in matters concerning Israel, but I have to admit I feel a rush of nationalism with each war or skirmish. I do know where my loyalties lie, but I am critical of the political structure of Israel, their policies, the predominance of religious conservatives, personal arrogance of many Israelis, and cruelty towards Palestinians by troops and some policies, even given the obvious provocations. I support the Gaza incursion – rockets cannot be disregarded. So I tend to hang with J-Street, the alternative to the very conservative, very nationalistic AIPAC.
I’m just trying to locate myself as a reporter for what I have just found in our trip to the Black Sea and to Istanbul.
When traveling, I like to read the local English language press. It usually is boosterish, often amateurish and provincial, and I’m never sure where it comes from, but I read it. At least you get to hear what’s in the air. Last year I read the English language newspaper in Dubai, which were boosterish. Didn’t say much about sovereign funds, as I remember. Last week we were in Istanbul for a couple of days, and I read the Hürriet Daily News. They covered Recip Tayyib Erdoğan, Prime Minister since 2003, head of the Islamist Peace and Development Party. From his Wikipedia entry:
As prime minister, Erdoğan implemented numerous reforms within a period of time. After 45 years, the negotiations for Turkey's accession to the EU started during Erdoğan's tenure. A great deal was achieved in democratization, attaining transparency, and preventing corruption. Parallel to this, inflation, which had for decades adversely affected the country's economy, was taken under control and the Turkish Lira retrieved its former prestige through the elimination of six zeros. Interest rates for public borrowings were pulled down; per capita income grew significantly. The AK party won the elections of 2007 making it the first time in 52 years that a party in power has increased its votes for a second term.
Of course, what isn’t mentioned is that he was an apparent supporter of the very provocative Gaza flotilla last month that Israel botched so terribly, succumbing to the provocation. Where has that vaunted Israeli ability gone, anyway? On the way to becoming just another Middle East country, I hope not?
The Hürriet Daily News featured an apparent ongoing conflict between the government and the armed forces. Turkey it has often been said, is not a country with a military, but a military with a country. Since the time of Ataturk, the military has led in modernization and secularization – so I’ve always been for it. Now, however, the Hürriet Daily News reports that the government wants the military to be led by civilian government, which would be ho-hum in any other country. That’s the way it seemed to be treated by the Hürriet Daily News, but this is Turkey, and Turkish civilian-military relations cannot be treated that way. So it was curious that the Hürriet Daily News seemed to be treating it that way.
What, in fact, is Erdoğan’s deal? His party is Islamist. He won power partly because of the former ruling coalition’s incompetence and corruption, but there is an Islamist tide in the world. There is more Islamic dress observed in Turkey than previously, and more religious orthodoxy.
Is the Erdoğan government pushing for geopolitical advantage from its crossroads position and it’s 8% economic growth per year? Or is there some true ideology involved? Was the posing with Ahmadinijad and voting against UN Iranian sanctions geopolitical, internal political, or ideological? Or reaction to being turned down by the EU, especially by France, which is having its own Islamic problems now?
Nothing is simple. After all, A.J.P. Taylor, perhaps the greatest English historian of the past generation argued that Hitler was actually a traditional politician in his aims and means – minus the Holocaust, I would assume – I have to reread that book, which I just saw in my bookshelf yesterday, actually. So the best leaders mix their aims and goals for maximum advantage. As Aaron Wildavsky used to say, never do anything for one reason only, even though he was only talking about academics.
But here is what else I saw in the Hürriet Daily News. Erdoğan declared that Turkey, Hamas, and others could not get their true story told because the worldwide media is controlled by Jews. He also said that the PKK, Kurdish separatist guerillas which has resisted Turkish repression for years, are agents of their Jewish and Israeli paymasters.
This material is unreported in our press, as far as I can see. If it has some validity, that this is what he is really saying, this is really some serious anti-Semitic shit. Next thing we’ll be hearing is the Protocols of Zion, the notorious Russian forgery of the secret Jewish plot to take over the world. Next thing we’ll be hearing is Holocaust denial from him.
As I say, I’m a secular Jew, and I’m pretty assimilated. I don’t look for anti-Semitism under every stone. I support Israel but only with reservations. But I also know, anti-Semitism is always there, ready to be reinvigorated. It lives and thrives in the European Left Wing and academia. And I know you can’t let anti-Semitism just burn itself out, because it won’t. Just like in a political campaign, you have to hit back early and often.
There is always more than meets the eye. The Israelis sure know what is going on, and they are in negotiations with Turkey, their best partner in the Muslim world. If Turkey really wants to grow, being able to trade with Israel and benefit from that vibrant economy is a better deal than the stagnation in other places, such as Iran. So I’m not jumping to conclusions.
But if this is accurate reporting, and this is really what he said – isn’t this dangerous? If this is true, if he is really saying these things, if the Hürriet Daily News has any validity at all – this is very scary stuff.
Budd Shenkin
I was raised a secular Jew and remain one, married twice, each time to a shiksa, and my kids view themselves as half-Jewish, which you can be if Judaism is a nationality and a cultural heritage rather than a religion. I try to be dispassionate in matters concerning Israel, but I have to admit I feel a rush of nationalism with each war or skirmish. I do know where my loyalties lie, but I am critical of the political structure of Israel, their policies, the predominance of religious conservatives, personal arrogance of many Israelis, and cruelty towards Palestinians by troops and some policies, even given the obvious provocations. I support the Gaza incursion – rockets cannot be disregarded. So I tend to hang with J-Street, the alternative to the very conservative, very nationalistic AIPAC.
I’m just trying to locate myself as a reporter for what I have just found in our trip to the Black Sea and to Istanbul.
When traveling, I like to read the local English language press. It usually is boosterish, often amateurish and provincial, and I’m never sure where it comes from, but I read it. At least you get to hear what’s in the air. Last year I read the English language newspaper in Dubai, which were boosterish. Didn’t say much about sovereign funds, as I remember. Last week we were in Istanbul for a couple of days, and I read the Hürriet Daily News. They covered Recip Tayyib Erdoğan, Prime Minister since 2003, head of the Islamist Peace and Development Party. From his Wikipedia entry:
As prime minister, Erdoğan implemented numerous reforms within a period of time. After 45 years, the negotiations for Turkey's accession to the EU started during Erdoğan's tenure. A great deal was achieved in democratization, attaining transparency, and preventing corruption. Parallel to this, inflation, which had for decades adversely affected the country's economy, was taken under control and the Turkish Lira retrieved its former prestige through the elimination of six zeros. Interest rates for public borrowings were pulled down; per capita income grew significantly. The AK party won the elections of 2007 making it the first time in 52 years that a party in power has increased its votes for a second term.
Of course, what isn’t mentioned is that he was an apparent supporter of the very provocative Gaza flotilla last month that Israel botched so terribly, succumbing to the provocation. Where has that vaunted Israeli ability gone, anyway? On the way to becoming just another Middle East country, I hope not?
The Hürriet Daily News featured an apparent ongoing conflict between the government and the armed forces. Turkey it has often been said, is not a country with a military, but a military with a country. Since the time of Ataturk, the military has led in modernization and secularization – so I’ve always been for it. Now, however, the Hürriet Daily News reports that the government wants the military to be led by civilian government, which would be ho-hum in any other country. That’s the way it seemed to be treated by the Hürriet Daily News, but this is Turkey, and Turkish civilian-military relations cannot be treated that way. So it was curious that the Hürriet Daily News seemed to be treating it that way.
What, in fact, is Erdoğan’s deal? His party is Islamist. He won power partly because of the former ruling coalition’s incompetence and corruption, but there is an Islamist tide in the world. There is more Islamic dress observed in Turkey than previously, and more religious orthodoxy.
Is the Erdoğan government pushing for geopolitical advantage from its crossroads position and it’s 8% economic growth per year? Or is there some true ideology involved? Was the posing with Ahmadinijad and voting against UN Iranian sanctions geopolitical, internal political, or ideological? Or reaction to being turned down by the EU, especially by France, which is having its own Islamic problems now?
Nothing is simple. After all, A.J.P. Taylor, perhaps the greatest English historian of the past generation argued that Hitler was actually a traditional politician in his aims and means – minus the Holocaust, I would assume – I have to reread that book, which I just saw in my bookshelf yesterday, actually. So the best leaders mix their aims and goals for maximum advantage. As Aaron Wildavsky used to say, never do anything for one reason only, even though he was only talking about academics.
But here is what else I saw in the Hürriet Daily News. Erdoğan declared that Turkey, Hamas, and others could not get their true story told because the worldwide media is controlled by Jews. He also said that the PKK, Kurdish separatist guerillas which has resisted Turkish repression for years, are agents of their Jewish and Israeli paymasters.
This material is unreported in our press, as far as I can see. If it has some validity, that this is what he is really saying, this is really some serious anti-Semitic shit. Next thing we’ll be hearing is the Protocols of Zion, the notorious Russian forgery of the secret Jewish plot to take over the world. Next thing we’ll be hearing is Holocaust denial from him.
As I say, I’m a secular Jew, and I’m pretty assimilated. I don’t look for anti-Semitism under every stone. I support Israel but only with reservations. But I also know, anti-Semitism is always there, ready to be reinvigorated. It lives and thrives in the European Left Wing and academia. And I know you can’t let anti-Semitism just burn itself out, because it won’t. Just like in a political campaign, you have to hit back early and often.
There is always more than meets the eye. The Israelis sure know what is going on, and they are in negotiations with Turkey, their best partner in the Muslim world. If Turkey really wants to grow, being able to trade with Israel and benefit from that vibrant economy is a better deal than the stagnation in other places, such as Iran. So I’m not jumping to conclusions.
But if this is accurate reporting, and this is really what he said – isn’t this dangerous? If this is true, if he is really saying these things, if the Hürriet Daily News has any validity at all – this is very scary stuff.
Budd Shenkin
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