The Devil's Chessboard

The Devil's Chessboard: Allen Dulles, The CIA, and the Rise of America's Secret Government, by David Talbot, HarperCollins, 2015.  http://www.amazon.com/Devils-Chessboard-Dulles-Americas-Government/dp/0062276166/ref=sr_1_1?ie=UTF8&qid=1462036454&sr=8-1&keywords=the+devil%27s+chessboard

I'm having trouble with this book – I'm just over halfway through it. I suggested this as reading for my great, great book club, Norm's Bookies, and then earlier this week I sent them a mea culpa note, regretting that I had done so. Here's what I said:

Gentlemen, I am embarrassed.  I've read almost half the Talbot book by now, I guess.  While there is a lot of interesting stuff, very interesting, it's far too long, not well edited, not terribly well written, and worst of all, the persistent lefty cant is really irritating.  I fear that as the part about the Kennedy assassination comes up, it will be even more irritating.  My favorite rendition of the assassination remains Steven King's.

But now I'm not so sure about my warning and apology. It's true that the style and organization of the book aren't great. It's overwritten at times, with attempts at grand phraseology that fall short. It certainly is filled with moral outrage of a type that I start to resent, because it feels like he is trying to make me feel outrage, and I'd rather come to that conclusion on my own. I've just had it up to here with people who demand that I think and feel the way they do. (And my good friend Bob didn't like Talbot's older book Brothers, which I did like, about how JFK challenged the military/secret government establishment and how there could have been an assassination plot, in fact, there probably was one. I liked it, but I respect Bob's opinion.)

But that doesn't make them wrong. I think that I have trouble with this because of me. I grew up in the fifties and I remember them as far from halcyon days. My parents had been Lefties and lived in fear of suffering for it, as many had. I even knew someone who occupies a couple of pages in the book, a man named Nathan Silvermaster, who I remembered was called Greg. Charged as a spy by Elizabeth Bentley, he was never convicted, and I knew him when he was a homebuilder on Long Beach Island, along with his business partner Lud Ullman, who lived with him and his (Silvermaster's) wife Helen, and built new ranch style homes on an island populated by Cape Cods. I remember his name in Time magazine. I told my 6^th grade class at Friends' Central, who knows what the discussion was but I never held back much then or now, so I said that we know people who are accused of being spies and “they're the nicest people.” My parents heard of this somehow – how had they heard of it, from friends who were the parents of a fellow student who were also Lefties, and who said, “Buddy Shenkin said...?” My parents were kindly, and even smiled, and told me that I had better be a little more careful about what I said. I'm wondering now how they found their way to Ullman and Silvermaster. It does appear that they were spies. https://en.wikipedia.org/wiki/Nathan_Gregory_Silvermaster I liked the house they built us.

Anyway, in the fifties my Dad wondered what magazines we ought to get regularly. They settled on The Nation and Scientific American. They would come in the mail and be put up on the hutch and I would come in from high school and look at them, the Nation with big Lefty headlines. Later on in the 60's in med school I would see my classmate Mona Bleiberg, from New Jersey, with her I. F. Stone Newsletter. My friend Fred Gardner at Harvard and his friend Todd Gitlin always knew the truth, and I went with Fred to audit the class given by Robert Paul Wolff on Marxian theory. I would read about The Power Elite by C. Wright Mills, J. Fred Cook about Cuba and what was Castro really and how was he being played by the Establishment (which isn't the term they used then,) and we read Vance Packard's The Hidden Persuaders in English class at school, and somewhere in there Thorstein Veblen's thesis on conspicuous consumption. But at the same time I wanted to be a baseball player when I grew up, and a doctor because that's what my father was, and we got new cars with triple toned paint jobs and fins and I learned to drive and hankered after girls, a lot, and loved high school at Lower Merion (way before Kobe got there.) And at Harvard Frank Bardacke urged us to read Dissent and to go sit in at Woolworth's in 1960, and my father said, be careful, you want to be a doctor, or something like that. I was cautioned.

So, what I'm saying is, when I read this book, all that comes crashing down on me. I wanted to be upright and I wanted to fit in and I wanted to listen to my parents and I wanted to succeed and I wanted to be an educated individual and one of those days I wanted to get laid. Then later, after I was a doctor and worked in the Public Health Service I went to the Graduate School of Public Policy at Berkeley and was exposed to smart and more conservative academics and I exposed my Lefty-ism and they helped me reason through it and by then I was old enough and experienced enough to accept some of their reasoning. I'm still working on it.

When we read we bring ourselves to the book. Everything is interactional. If you believe in history, and I believe in history, and culture, then you believe that the past matters to the present. I think of budgeting – what's the first step in making a budget? Look at spending the year before, then adjust. Isn't that all of life? So, the fifties matter a lot.

It really is unconscionable what Dulles and the CIA did, and it lives today. Here's a Huffington Post review of the book that makes my recommendation more palatable: http://www.huffingtonpost.com/joseph-a-palermo/the-devils-chessboard-all_b_8959302.html.

I wonder if Talbot is truthful, I guess that's part of my problem. How has he learned all this, and how sure is the history? I guess I would feel a lot better about the book if I had a better sense of what he is sure of, and what opposition to his story says. Do they accept the facts, but cast them in a different light? Or do they rebut the facts?  But then I think, yes, what he says has the ring of truth.  It's just uncomfortable.

The past lives in our lives as a country, as well as my past lives in all the books I read.

Hey, book club guys – I now think the book is worth reading. From this mess came the revolt of the 60's, which spawned Reagan and the shadow of conservatism that we have lived our lives under, even as it appears the Republican party is set to lose an election, and we'll see what difference that makes. It does appear that Cuba is out from the cold. I guess.

Budd Shenkin

Race and the Presidency

This is a mini-post. I have had so many ideas running around in my head, and some writing I've been doing for other projects that I'm now reduced to a mini-post, with possibly others to follow. Who knows? I've never been one for planning, sometimes to my detriment. My redeeming quality has been persistence and the capacity for hard work. I keep coming back.

Anyway, mini-post. Toni Morrison in 1998 reflected on the impeachment of Bill Clinton. (Amazing how that has receded, isn't it?) She said, “White skin notwithstanding, this is our first black President. Blacker than any actual black person who could ever be elected in our children’s lifetime. After all, Clinton displays almost every trope of blackness: single-parent household, born poor, working-class, saxophone-playing, McDonald’s-and-junk-food-loving boy from Arkansas.”

She said the message of the Establishment to Clinton, as to any African-American, was this: “'No matter how smart you are, how hard you work, how much coin you earn for us, we will put you in your place or put you out of the place you have somehow, albeit with our permission, achieved. You will be fired from your job, sent away in disgrace, and—who knows?—maybe sentenced and jailed to boot.'”

She continued: “This is Slaughtergate. A sustained, bloody, arrogant coup d’état. The Presidency is being stolen from us. And the people know it.”

http://www.newyorker.com/magazine/1998/10/05/comment-6543

Today, a phrase in Paul Krugman's trenchant column on how the Republican Establishment has conned its way through the decades caught my eye: “after seven years of an African-American president (who the establishment has done its best to demonize)....”

This is not new, but when I heard it this time, I thought: you know, racism is so pervasive that there is no magic bullet, it really has to be taken on in stages. Clinton was stage one, a white man with some familiar African-American characteristics, according to Morrison. And Obama is stage two. Only stage two because being African-American isn't just about skin color, it's about culture and experience. Obama's skin color is dark, but he was raised by a white mother and white grandparents from Kansas living in Hawaii. True, not the total white experience – Indonesia and Hawaii are not Kansas.

The ambiguity was sufficient for many African-Americans to say he wasn't black enough to qualify as a Black President. But certainly prejudiced whites viewed him as plenty Black. And that was the label he embraced. If he was viewed by white society as Black, then let's be Black, he said. He chose a spouse who was fully African-American. And then he populated his government with many true African-Americans. One step further than Bill Clinton, I'd say, maybe a step and a half. Black he was but he still was raised by a non-prejudiced white family – his grandparents were really remarkable, both of them, the way they raised that boy. I'm all admiration.

Then as President he got the full illegitimate treatment from Mitch McConnell and other Southern friends – we'll break this Black boy, essentially. We'll challenge his birth, we'll block anything he wants to do. We'll put him in his place.

Well, it didn't work out that way, Mitch. The Confederacy may still live, but it's still shrinking.

Anyway, like I said, a mini-post. Just an observation. My own view is optimistic. Obama has clearly been a superior President in so many ways, and his no-drama temperament has been perhaps the strongest weapon of all. What a gift it is. Basically, I think Obama is step two or two and a half in a three step process. Next time, no more illegitimacy; next time, it will be just on the merits.

Hopefully.

Budd Shenkin

Primary Pediatrics Laboratory #2

Readers have responded to my proposal for a Primary Pediatrics Laboratory.

#1 Some have pointed out that the proposal needs to meet the objection that it ignores the needs of the general population and might be seen as promoting a double (or even more levels) standard of care.

#2 Others have wondered if we should be looking for ways to test better methods and increasing use of midlevel practitioners as a way of stretching scarce resources of money and personnel.

Answer to objection #1: Building the ideal in a model practice is just that, building an ideal. It's not a prescription for a whole system. You put all your money and effort into building the Warriors, and then the rest of the basketball world can look on with wonder, and emulate as possible. The Warriors inspire, and they instruct. Laws then support a fair distribution of resources. Building the Warriors doesn't hurt, rather it helps the school teams and summer leagues around the nation.

Answer to objection #2: the PPL is kind of a mind bender, or paradigm shifter.  We are so used to operating under budget constraints and being good citizens in primary care.  Think like a procedural specialist where the money just rolls in -- think fine art and walnut paneling of our cardiology colleagues instead.  They are used to thinking in exactly the opposite way we think.

Imagine if cost were no object -- no object.  Where the task was to go higher and higher in every way.  Think different.  Does anyone think about cost when designing a new, better aortic valve?  Etc.  Think about primary care being the Cadillac,  What would you do?

In fact, in an academic center where money could be abundant, could you achieve the highest quality care possible?  No one really tries.  Primary care tries tries this and that, but not the whole ball of wax.  But it is possible to do so.  The barrier is simply our way of thinking.

Benefactors generally think of the traditional -- more top heart surgery, more that sort of stuff, more really deluxe hospitals.  Benefactors want to see kids in their beds getting better because of something their money bought.  But benefactors also think of fixing education in primary care terms, so it is possible that they could look at things differently.  What they need is a proselytizer.  I haven't seen that pediatric primary care proselytizer; the world is looking for that leader.

Think of the Peter Bent Brigham Hospital and the recent scandal of treating a Middle Eastern prince differently as they rent out several rooms on the top floor.  What if, instead of attracting royalty for specialty services, someplace like the Brigham hoped to construct the same quality service for primary care, no costs too high, no patient/clinician ratio too low?  What could one do?  I can think of lots of things.

Someone will want to be that leader. I wonder where it will be.

Budd Shenkin

Warriors!

Dedicated readers and friends are aware of my Philadelphia roots. It's been pointed out to me, perhaps by my wife but I think also in the more public media, that Philadelphians are very loyal, even when they move away. Ann herself aids me in this sentimental attachment, as she refuses to allow that after over 40 years of residence that I might have become a Californian. Nope! So, not to be stateless, in the eyes of intramarital law I might still be a Philadelphian.

There are circumstances, however, that blur the line. Two of our teams here in Oakland, like me, have Philadelphia roots, the A's and the Warriors. So in fact I have two double home teams, and can be doubly proud of both for their past or present preeminence. For the A's it's the past. For the Warriors, however, always my team, and always the vehicle for glorying not only in Philadelphia but also in the game of basketball, the time is now.

What a team! If only Curry were from Philadelphia and not North Carolina! But I'll give him a pass. As my ticket-partner Lois said at the Giants game on opening day, his parents can certainly take pride in the way they brought him up – and she wasn't referring to teaching him how to shoot. What a great young man, it seems. And what a great team.

Which brings us up to date on the controversy, whenever basketball greatness arises – who is best? My close and lifelong friend Bob Levin (TheBobLevin.com) has assembled a small but lively and certainly well-informed email basketball and Philadelphia and Warriors conversational group, the latest addition to which is one Eric Bernthal. Eric opined:

Here’s a comparison which does have substance and reasoning (and some kind of hocus-pocus computer “simulation” to create an aura of authenticity),  http://www.sportsline.com/insiders/25378236/would-stephs-warriors-take-down-michaels-bulls/,  but when you read it, I think you’re struck by just one thing: how incredibly well-matched these teams are. (The matching, seven-foot, Australian centers provide a great start.)

As much as I love the Warriors (and I really do), I think there are still two immutable points that say that – as of today – the Bulls are better: first, the Bulls were dominant for a much longer time; maybe the Dubs will get there, but maybe not. The Warriors have to prove that they have the endurance, discipline, good health and good fortune to last a lot longer than they have before anyone can anoint them credibly as the greatest team ever.  Second, there is still only one Michael Jordan.  Maybe, three or four years from now, Steph will be seen as one of the greatest of all-time, but you just can’t make the case today. It’s too soon. (I also think that he’s more likely to go down in history like Iverson than Jordan – spectacularly accomplished for his size and weight, a tremendous competitor and dazzlingly talented, but not the greatest of them all. That’s Jordan. It’s only Jordan.)

In one respect, though, the Warriors totally dominate the Bulls: likeability. You have to love Curry, and no one could love Jordan; you have to love Green, and no one could love Pippen; okay, maybe Klay Thompson isn’t totally loveable, but he’s sure no Dennis Rodman.

And I rejoined:

Generally right.

But ... Curry has been simply incredible, just differently from Michael.  Finesse over power.  What an array of shots!  High, high off the backboard - he basically invented a way for small to beat big.  Innovative.

Also, Iverson never really made his teammates so much better, the way Curry does.  Iverson was more like a better Monta Ellis with some extra moves.

Also, "likability" is more than just likability.  It's a far different experience to have a joyful team cheering each other, with leadership distributed, rather than a dominated team with a black heart.  I think that joyfulness is part of quality.  Curry not only makes the whole team better, the Warriors make all of us better.

And Eric rejoined:

I don’t disagree with a word of that. I watched them beat San Antonio the other night, and it is indeed pure joy to watch them, not just as basketball players, but as great young men relating with enthusiasm and warmth toward each other. And in terms of character, to the extent this stuff is really knowable from afar, Curry and Jordan represent the two absolute extremes.

Later on, Bob added this:

http://www.cbssports.com/nba/eye-on-basketball/25377879/bulls-vs-2015-warriors-2k-simulation-new-age-trumps-old-school.

My old Philadelphia friend John Bernard, when a student at Swarthmore, invited a celebrated Philadelphia Daily News sports columnist to speak, a man he had read daily for years. (Could it have been San Hochman?)  John asked him privately why a smart guy like him devoted himself to the essentially trivial pursuit of sports. The writer replied that you see all of life in sports. The younger guy coming up to challenge the veteran, for instance. And so much more.

Another answer could have been, life is sports.

Budd Shenkin

The Downside of Corporate Medicine

The love fest for Kaiser has always rankled me.  Yes, they have good preventive statistics – but they would, wouldn’t they, isn’t that exactly what they would be good at, treating everyone the same?  It’s good to do so sometimes, but sometimes not.  I’m not of the school of “no cookbook medicine, please,” because sometimes cookbooks work just fine.  But decreasing variation and increasing quality is far from the whole story.  Corporate behavior has been chronicled too thoroughly – Dilbert! – to be summarily dismissed as irrelevant.

Consider this story given by a mother before the first year class of UCSF yesterday.  The patient was the mother’s ten-year-old daughter.  Her father was – is – a very productive family practice doc working for Kaiser.  They were all Kaiser patients, of course.  Unfortunately, the ten-year-old started losing weight and had other signs of anorexia nervosa.  They brought her to the Kaiser doctor.  The Kaiser protocol for anorexia nervosa states that the diagnosis of AN cannot be entertained for a child less than 13 years old.  Hence, instead of hearing the diagnosis of AN, the family was told that “we’ll see how it goes” and they would need to wait a few years before doing anything.

This is a faulty protocol.  AN happens to younger kids all the time.  Protocols can be faulty.  But the issue is, what course did corporate medicine take then?

The family protested within the Kaiser system.  The mother and the father advocated.  Corporate Kaiser resisted.  No change was made in the treatment of the child or in the protocol.  The family was admonished for protesting.  The child was taken to UCSF for the appropriate treatment.  That’s right, they had to go out of system.  Eventually, I imagine Kaiser will have to pay the medical bills, if the family is insistent enough.

Meanwhile, the physician father, who was a productive physician and had received a bonus for his work every year, this year was denied his bonus.

Kaiser is a prepaid system, and every disease means money lost; other systems are fee for service, so every disease means money made.  Thus, following the money, Kaiser advertises its preventive programs – Thrive!  If you are healthy, come to us!  Other systems advertise their cancer programs, their heart programs, etc.  One system is tempted to under-treat, the other to over-treat.  But the more they are all corporate, and the less the decision-makers in each structure personally face the patients they affect, the more they will all follow typical corporate incentives.  Sometimes it’s OK to do so – “population medicine,” figuring out what course of action benefits most of the people, is sometimes right.  Corporations can do this better than individual practices, probably (only probably, though, since nothing has been proved – in the end, money talks, and we don’t know what it’s saying yet.)

American medicine is becoming more and more corporate.  The profession itself needs to become aware of the pitfalls and erect ethical corporate procedures to protect the individual clinicians -- where the true repository of medical ethics will reside -- and their patients.  And the patients need to be viewed as the clinicians’ patients, not the corporation’s patients.  Or else inappropriate protocols will rule, and bonuses will be taken away from those who protect their patients and their daughters.

Corporations, my friends, are not people.

Budd Shenkin

The Primary Pediatrics Laboratory

World!  Listen up!  Here is an innovative proposal, and you are getting it for free!  Oh, the wonders of the internet!

                              The Primary Pediatrics Laboratory

An Innovative Proposal For Dynamic Progress In Primary Care Pediatrics

Introduction

I have a friend who is a Silicon Valley CEO with small children.  His own doctor was at Palo Alto Medical Foundation, so it was natural for him to enroll his children there as well.  The children are healthy but with some of the usual problems, including allergy, and he and his wife have many of the usual parent questions.  As high achievers themselves, they naturally try to find the best for their family, especially since they view raising their children as their most important responsibility.  What happened with them is very interesting.

For a while they continued at PAMF.  A couple of times I got some phone calls from the mother of the family for rather typical children's health issues.  I was very happy to answer them – we are friends, and I never mind questions – but it made me think that maybe they wasn't getting all they needed from their pediatrician.  Then I heard from them that they had not only left PAMF, but they had left Silicon Valley for a very expensive concierge pediatrician in San Francisco.

They told me the story of why they left.  One incident occurred when their eldest child, who is allergic, was sent for an allergy consultation.  When they visited their primary pediatrician to follow up, he looked to his computer, eventually was able to find the allergist's report and to read it, and they then discussed it.  But somehow it didn't resonate with the family.  By contrast, when they visited the concierge pediatrician, he sent their little girl to two different allergists, talked to them personally, and then discussed the two reports with the parents personally, and they jointly came up with a plan.  The difference was stark.

Now, technically, which care was better quality?  It's hard to tell; who knows?  But what is very clear is the nature of the doctor-patient relationship.  One was more distant, even though it was probably competent.  The concierge practitioner, however, was clearly involved and personal, and the idea of getting two separate opinions, and the idea that the primary pediatrician spoke personally to both of them, bespeaks a commitment to involved and personal care that is unmistakable.  Even if closer examination were to reveal that the actual advice of the allergist at PAMF were identical to the other two, and that the essential difference of PAMF and concierge was really marketing with no difference in technical quality, nonetheless, quality is not just technical.  Quality is also feeling and connection.


Reflections

This vignette brought many thoughts to mind. 

One, we know that the concierge medicine and direct primary care are growing quickly.  This family's decision puts a face to the statistics

Two, while the market is producing concierge practices, why aren't the major medical centers and teaching institutions involved?  Is the market too small to be concerned?  Is there nothing to teach or to be learned from concierge-style practices?  Are these institutions afraid of the stigma of not caring about costs and serving the upper income segment well – in other words, is equality trumping quality? Are the large institutions missing a boat?

So I pondered, and that pondering led me to the proposal I am presenting with this paper.


A Proposal for Academic Pediatric Medical Centers to Found New Programs, Primary  Pediatrics Laboratories (PPL)

It seems to me that there is in fact a great deal to learn from the movement to concierge care.  Concierge care seems to offer accessibility, involvement, and intensity that is beyond the reach of current models.  It has something to teach us about the economics of primary care – what degree of increase of funding is necessary to achieve higher quality?  It might also have something to teach us about technical quality of care.  The best way for great institutions to learn about concierge care would be not only to study it, but to emulate it, to compete with others in serving patients with concierge-style care – in short, to learn more by doing.  By actually doing it, since medical centers have so many more resources than the typical concierge practice – not just financial, but technical resources, expertise, and brain-power as well – it's quite possible that the medical centers would come to invent new ways to deliver care that would lead the world of pediatrics.

How could this be done?  I would propose that a medical center establish a concierge-style practice that could be called The Primary Pediatrics Laboratory (PPL), which would be a concierge-style practice centered beginning at a single site.   The PPL would need its own Board and budget.  It would raise money not only from fees and medical center resources, but from grants from companies and individuals who want to be part of significant advance in providing care, using and developing hi-tech and hi-touch systems, some of which might be the core competency of some of the donor companies and individuals.  Unlike most other current primary care organizational efforts, it would not be centered on lowering cost.  Instead, it would intend to invent prototypes of new paradigms of care.

The objectives of the PPL program would be:

• to provide care to patients at the very forefront of the best of concierge care
• to invent and pioneer new technology and other new techniques in the service of personal care
•  to conduct research on high level primary care with the development of new services and techniques
• to teach selected residents in pediatrics what the best in primary care looks like
• to transfer many of the techniques from SPPL to associated networks and faculty practices
• and to conduct research on the transference experience and scalability of the innovations

Part of the idea of the PPL would be to bring together the highest quality minds and experience for this best in the world effort.  Because of the mission, PPL should attract personnel of the very highest calibre.  The Board of Directors would be composed of some of these high-grade minds, from the worlds of academic medicine, medical practice, organizational and business theory, and the world of technology.  Parents should also probably be represented, and maybe even a teenage patient.

The physician staff would be composed of experienced physicians recruited from the private world and the academic world, including some of the best young faculty or recent graduates who have been devoting themselves to primary care, and who believe in the mission of strong primary care.  For this effort, it would be important to transcend the traditional rift between academia and practice.  It would also be important for experienced and very skilled administrators to be part of  the PPL, and for clinicians and administrators to work closely together.

The beginning PPL should at be composed of 5-10 clinicians, mostly pediatricians but also advanced nurse practitioners.  For adolescents, the PPL would offer the option for patients to be seen by an adolescent specialist at the PPL office.  The ratio of clinician to patients would be about 1:500.  It is possible that some of the patients who would be accepted into the PPL could be connected to the initial donors, either company employees or family members, etc.  In addition, “scholarship” support would be available for other families not so financially blessed.  The patients would be expected to share in the running and research of the PPL, giving feedback and suggestions. 

The services offered by the PPL would be as attentive as the most attentive concierge practices.  The exact services would be developed by the Board and staff in the planning stage.  The services would have to include 24/7 connectivity with the physician on call (as opposed to some concierge practices that apparently have 24/7 coverage by the actual personal physician.)  The actual personal pediatrician would be available if necessary 24/7 if the on-call doc needed to call him or her.  Appointments would be same day available on a very convenient basis, etc.  In addition, every technological advance would be available, including several types of telehealth.  Cognitive aides such as the Isabel program would be used.  The EMR resources of the medical center would be a part of the PPL, but would have to be open to customization for the PP.  Classes of all sorts would be offered to patients and parents and support groups would be utilized.  The Board and all staff would be challenged to develop even more services.  Specialist consultation could offer the opportunity for immediate telephone availability while the patient is in the office, very prompt appointments would be available, and nationwide consultation for difficult cases would be possible.  Population health would also be practiced, as the PPL viewed its patients collectively, assessed those groups at risk, educated those groups who had the need (e.g., adolescents and sexual/reproductive health, behavioral health, and preventive medicine.)

Internally at the PPL, procedures to promote quality would be the best possible, and would exceed any of such practices in the private concierge world.  Consistent review among clinicians of their cases and charts at conferences with others of the group would be effected.  Attention would be paid to diagnostic errors and the cognitive errors that engender them.  HEDIS, P4P measures, NCQA Medical Home, and other quality markers would be observed, but the quality of the PPL would be such that the PPL would blow by those markers and set its own standards.  Attention to administrative practices in the office would be extensive.  Again, the idea would not be to save money.  Overstaffing by conventional measures would be the rule.  The idea would be to produce a gold-plated practice, the best possible. 

In time, the PPL could expand to other sites with special emphases as they develop.  It wold be expected that as certain lines of service would start to yield fruit, the principals might want to found another practice that could work on those lines intensively, and one would also hope that demand for the PPL services would fuel expansion.


Financing

Financing the PPL should be relatively easy.  Concierge practices typically charge patients a yearly fee of $1,000 to $2,000 per patient, and they collect fee for service as well.  In addition, funding the research agenda and the startup costs should be supported by donating individuals and industry, which would then look forward to cooperating with the PPL on some projects and sending many of their family and employees to the PPL for care.  Proper budgeting would produce a program that would not lose money, and the goal would be to turn a modest profit.


The Research Agenda

To give an idea of what the research agenda might be like, here are some imaginary titles for papers that could emanate from the PPL. 

Comparative Costs and Benefits in the Primary Care Armamentarium: Telehealth, 24 hour On-call, and Immediate Scheduling Compared and Contrasted
The Primary Pediatrics Team: Acceptable Roles for Advanced Practice Nurses in a High-functioning System
How High-tech High-touch Primary Care Impacts the System: Reactions of Specialists to the New System of Primary Care
Coordination of Care in the Hospital: How Primary Pediatricians Can Work with Hospitalists If They Have Time
Is More Expensive Primary Care More Costly?  An Inquiry into the System-wide Effects of Hi-tech High-touch Primary Care
Proactive Prevention in Pediatrics: the Use of Technology in Promoting Health Behaviors in Adolescents
Sensing Depression and Drug Use: How New Technologies Can Send Warning Signals to Primary Pediatricians
Technology and Medical Practice: Is the Doctor Necessary for a Technology-based Family?
Ideal Primary Pediatrics: The Dimensions of a High-functioning system
Sharing the Medical Record with the Patient When You Have Time: Does it Make a Difference?


Advantages

The payoffs  of the PPL for the medical center could be many. 

It is always good to be a world leader.  Currently there are few universities or hospitals that are making significant strides forward in primary care organization and quality.  Hospital-based services and specialty procedures and research still reign supreme, as the primary care day is dawning only fitfully.  Most medical centers are caught up in ACOs, coordination of services, introduction of EMRs and other such matters.  There is no group that I am aware of setting its sights on what would be the PPL objectives. 

The PPL could cement the relationship between the local business and technology community to the benefit of both, in many ways.  Just having the availability of prime grade pediatric care for the personnel of the donating institutions could yield great dividends.

The PPL could enhance the image of the medical center as “the” place for children's health.

The PPL concepts and techniques, when spread to the associated networks, would serve to further enhance the market share of those networks, and lead other practices to join it.

The idea of a primary care “lab,” perhaps even reminiscent of Bell Labs and Xerox, could stir enthusiasm for the sponsoring medical center worldwide.

It would probably be good at this point to mention a potential negative.  Many think that the whole concept of “concierge” is too financially driven, and that it is in some sense even ethically compromised, since the profession of medicine  professes its ideal to serve everyone.  I believe that this argument could be countered by asserting that equality should not be the enemy of quality, and that such an effort seeds elements that are readily adoptable by other systems.  In addition, when the market is telling us that there is a place for concierge care, it is important to listen and to respond in a way that allays the ethical concerns that might arise. 


Conclusion

This paper obviously is a quick sketch designed to provoke the imagination to think about a new pathway.  The concept outlined here isn't being done anywhere that I am aware of.  I believe that the PPL would be consonant with the goals of excellence set by ambitious academic medical centers in their other fields of concentrated effort.  Marketing would be easy, as would financing.  There is no reason to think that embarking on this program would detract from other medical center efforts; in fact, the opposite would probably be true.  Interaction with the specialty departments, for instance, would give a sense to them about what it means to truly serve patients to the highest degree.

In sum, I believe this proposal would be an opportunity for a major pediatric medical center to steal a march on the academic and hospital fields and emerge an innovative leader in primary care, an area that is increasingly recognized as important, but where research and practice still languishes.


Budd N. Shenkin, MD, MAPA
buddshenkin@gmail.com

When It Just Pops Into Your Head

Just the other day I had the same experience we all have had – I couldn't think of something, a name. I reached and reached, I tried to think of a place to put with the name, I reached for something to prompt me, a sound, a letter, and nothing came. I knew I knew it but I couldn't reach it. But then I also knew what I had to do. I had to relax, I had to distract myself, I had to think of something else, and I had to have faith that it would come.

And of course, it did. The name – whatever it was, I forget now [(:-)] – just popped up from somewhere. Eureka! That's it! Thank you!

It popped up. How did that happen? Where did it come from? Why did it come? Good questions.

The best I can explain it is this, although there are probably some brain scientists who can do a better job, now that so much more is being discovered, especially in the last five years: it comes from the Right Brain. If it comes from the Left Brain, “you” can see how it comes. You follow your reasoning, you make the proper associations, you envision the letters of the name, you have an actual prompt that you always use as a clue because this is something you regularly forget, you have a sound that you remember, and association you use, etc. And whatever that process is, “you” see it.

But, there are other parts of your brain that “you” can't see working. “You” don't know how they work, because it's another process, and it's actually coming from somewhere else that's inaccessible to “you.” But you do see the result in a popup message, so you know that somewhere, something is happening. And it's got to be you, where else could it come from? You just couldn't see the process.

As I say, with all the work being done with functional MRI and other methods, the sites of this memory retrieval are probably already known – I've got to find out where to find this out. Or I don't know, maybe it will just come to me.

But now, here's the point of this post. I bet that other things “just come to us” the same way, things that are not memories. Take, for instance, something that has always puzzled non-religious people who have problems with alcohol – the “higher power.” At some point and alcoholic has to realize that as hard as they try, as much as they try to exert willpower, they can't quit alcohol “by themselves.” Just as reaching for that missing memory isn't susceptible to harder and harder Left Brain work, trying harder and harder not to drink ends in failure. So you have to give up in order to finally win. You have to invoke the help of a “higher power.”

I think that that “higher power” is the same thing as waiting for the memory to pop up, except that it's a lot harder. You just can't approach it directly. It's like taking a shot in basketball, or pitching in baseball – it is a sin to “aim it.” You have to let it fly and have faith. Aim it and die.

Of course, before you let it loose and pray, you need to practice a lot. You need to get a feel for the process and do lots of reps. But then in the end it just comes. You meet with others and think and talk about alcohol, and what role it plays, and how it is destructive, and what it means to you, and how fearful you are if you don't have access to it – and then you just have to hope that “it” comes. Where will it come from? The Right Brain? I think so. With the Right Brain, all the work is in preparation. If you never knew the name you are looking for in the first place, it won't come; if you haven't studied and thought and discussed about alcohol and overcome your shame and self-accusation, it won't come; if you haven't thrown up 10,000 shots from 28 feet (wait, that's a gross underestimate, but you get the point), it won't come. But when it does come, we experience it as a gift.

Maybe this is what people mean when they say that God is within you. Maybe this is what comes when you pray and you see the light. Maybe this is like what comes from dreams, another mysterious working of the brain that isn't just brute logic, something that kind of edges in there. Maybe this is what they say when they say dieting doesn't work, you just have to edge up to best practices of living. Maybe it's all those things.

Like relativity came to Einstein after he thought and thought about it from his childhood story of what it would be like to ride a light wave and it kind of burrowed into this head, and he worked so hard to see clocks and trains and mathematics and physics research, and then it just came. He had his Eureka! Moment, and he experienced it as a gift.

The mind is a mysterious thing. My old professor of biology, George Wald, said that the two big biological challenges of our time would be the secret of creation of life – organic molecules in a soup and lightening striking – and the secrets of the brain, and that the first would be solved in our lifetimes but the second not. Well, the first still isn't solved, which comes as a surprise. Maybe it's harder than we thought. It is true that the problem of the brain won't be solved for a long time, certainly, but recent progress has been astounding. I have to learn more about it. Meanwhile, I wouldn't be surprised if sometime soon the problem of where these popup thoughts come from will be solved. Some brain scientist will work very hard on it and then one night it will just come to him.

Budd Shenkin