What Is To Be Done?

My close friend Rick responds to my first post today:

Only a madman wouldn't agree with your frustration, anger and fear about what is happening.  RFK is one thing, but the insanity is everywhere: from breathtaking conflicts of interest (the FAA today is reported to be cancelling its $4 billlion contract with Verizon — to award the work to Elon Musk!!)  to unimaginable insensitivity to human suffering (hundreds of thousands of people who depend on USAID for basic food/survival have been suddenly cut off and literally left to die. Research programs are stopped, whole departments are experiencing massive layoffs without plan or reason. Migrants are being treated like terrorists and locked up in Gitmo. Our allies are being treated like our enemies, and our enemies are being courted like allies. Tariffs will soon cut us out of all global markets, handing them to the Chinese. Musk's mission is being managed by a 23-year old and a 25-year old with no prior government experience, slashing jobs with their machetes (much like the Red Guard in China).  History is brazenly rewritten with no thought for the truth ("Zelensky is a dictator!  Ukraine started the war!"). Trump calls himself "King" and talks about a third term (although all that may be deliberate bombast from him).  The EPA is being dismantled; so is the FAA. So is the FDA.  The FBI and DOJ are now partisan arms of the presidency, positioned to pursue his political enemies with abandon. 

God help us.

But when you say that the Dems are organizing to fight, I remain very skeptical.  Lawsuits?  Sure, bring 'em. But don't count on the courts to support you. Filibusters? Sure, they can work to delay pieces of legislation here or there, but the public hates it, thinks that's a big part of the problem, and they will not reward the Dems at election time for scorched earth legislative tactics. 

Maybe there are emerging Democratic leaders who will make sense and draw support. I'm skeptical. I suspect we're going to be riding this madness for four more years and can only hope that the country holds together that long. 

I responded to Rick:

I think resistance is necessary.  Playing dead turns out to being dead.

What kind of resistance?  I think it's got to be explaining what's happening.  Understanding comes first.  Find ways to communicate.  Work hard at it.  Find out who can do it, and how.  Refuse to be suppressed.  It's necessary to fan the flames of a popular movement, and find the leaders, and the group of leaders.

BTW - In making the case, I would show what happened in Hungary, and compare it to what is happening with Trump.  It's also what happened in Putin's Russia -- the co-conspirators loot the public treasury.  That's something people can understand.

One more thing - how do you convince people?  You tell them, you tell them again, and you don't stop telling them.  Did you even hit a nail just once, and see your work done?  Nope - you have to drive it in again and again.  It's the same with public opinion.  Gotta drive it home.

Myself, I'd also do it not just with domestic issues, but with foreign policy.  I know traditionally the public "doesn't pay attention," but I don't believe that's always true.  "We are now lining up with our enemies, Communist Russia has become Oligarch Russia - and we're lining up with them!  Who are our oligarchs - name them!  What are they doing with the press - show the examples.

The problem of democracy is that it presents tools for a determined group of anti-democrats to take over the levers of power.  That's what we're seeing here.  The very last guardrail is public opinion, and that must be the aim of the resistance now.  Public Opinion.

Budd Shenkin

It Looks Like Our Epoch Really Sucks

​I looked at what RFK Jr is doing now. Might as well put the Taliban in charge, I thought, not totally logically, but that's what I thought. Put a stop to all that vaccine development - thanks, you awful twisted stupid damaged POS. And then I posted about our current condition:

Stupid, Destructive, Mean, Greedy.

Not to mention psychopathic and sociopathic.

How long, o God, how long?

This is just the start.

The worst era ever has begun.

This all happens and Carville and others, the "we have no power" crowd, say let it fall, and let people know who's responsible. I say, AYFKM?? That's such a responsible look! Don't you realize that Dems were deposed partially because they were seen as being ineffective, as "Not keeping us safe?" That's what the crime in the streets, making theft a misdemeanor, not protecting the borders is about, to some extent. It's not all just xenophobia and prejudice. Ineffective and misguided, those are the charges. Not being focused on the real problems, which is not misuse of pronouns, and then keeping a government that takes 8 years to get anything done. You really want to add more substance to the charge of "ineffective?"

So, help is coming, resistance is coming, we just don't know from where. The state AG's are coming together. The Blue State governors will be coming together. Pete Buttigieg is there, organizing and verbalizing. I hope the formal congressional leadership will have the wisdom, even if they keep their titles, to step aside and let the capable Dems come to the fore, those who know how to act, how to explain, how to persuade.

Meanwhile, how mean and stupid can they be? We're finding out.

Budd Shenkin

Resistance To Trump Coup - We Need Political Resistance Councils

It is astonishing that the Democratic party is even weaker than we thought it was. We’ve known that it’s sclerotic and geriatric, we’ve known that the leadership can’t talk its way out of a paper bag, we’ve known that it is riven by interests with singular, narrow foci. We’ve known that its kennel of consultants is mediocre in everything but continuing to get contracts for their mediocre services. We know that its leadership has been mostly focused on keeping officials in their jobs. We’ve known that the official leadership has few leaders. We’ve known that the senior leadership has occupied itself with keeping talented junior leaders out of leadership, and comfortably stifled so that little need change within the Democratic party apparatus. We’ve known that, even to the end, when the institutions supplied all the tools necessary to cage the tiger, they couldn’t get traction on the Mueller Report, and even when they were in power, all they could offer was the infuriatingly incompetent and much-more-than-cautious Merrick Garland, may his name live in perpetual infamy. No one even raised a rumpus about his two years of delay, and his appointment of sworn Biden enemies to investigate him and his family. No, silence is their specialty.

Yes, the evidence was there. The congressional leaders couldn’t even give a coherent speech — Schumer reads his speech into the lectern, and for all her virtues, Pelosi’s ability to explain and inspire is in the bottom 20th percentile. Those who could speak had to do it on their own, in what TV time they could cadge. The evidence was there.

But still. One has to still be astounded at the confused passivity of the Democratic party in the face of a coup — or an autogolpe — that was telegraphed explicitly by Trump. He said what he was going to do! Project 2025 laid out the roadmap! Trump said his appointments would be different this time! He said he would have a tariff war! He said he would side with Russia! He said Urban has it right! He even said that in his view elections were unnecessary.

So don’t act surprised, you dolts. Yes, you are deer in the headlights. You just aren’t the right person for the job that has to be done now. Schumer, where is he? Any leaders think of bringing the senate to a standstill, filibustering appointments that are in themselves a punch in the face? Chris Murphy and others urge leaders to shut the Senate down, but they don’t. Are Republicans the only ones who own the filibuster? Anyone think of stopping calling the paid-off and intimidated Republicans anything except “our esteemed friends on the other side of the aisle?” They are the enemy! Ever hear the term “going to the mattresses?” If not now, when?

Listen to the rally cry of our friends Chuck and Hakeem — “We have no power!” Wow, that will get the millions cheering. Passivity is widespread. Jackie Rosen, fresh off a difficult race for senator from Nevada, when she should be ebullient and energized that she won, instead echoes — “We’re the minority.” Hakeem goes off on a book tour to Chicago — I guess there’s nothing to do in Washington because, after all, you’re in the minority.

OK, people tell me: don’t get angry at the Democrats, get angry at the Republicans, they’re the one doing the damage. I say, look at sports. If an opposing team gets stronger and your home team doesn’t meet the challenge, do you get angry at the opposition, or do you assail you home ownership — what are you doing? Are you just cheap? Are you thinking of moving away and you want to lose? What’s your GM doing? You get angry at the malfeasance of your team, not the strength of the opposition. I admit the analogy breaks down when it comes to cheating — the Astros will never be forgiven, and there was Inflategate. We can indict Trump for his lying and cheating — but after all, did the Dems make good on it when they had control of the DOJ? Answer — no, they whiffed. Which they are very good at doing. I’m really pissed.

So OK, I’m pissed off. But what is to be done? Most of them recognize the danger, they see the ongoing destruction, but they were somehow built for another situation, for quiet discussions and compromise, for mutual respect of differences. They weren’t built for war. But war has come for them. It was coming, but most people wish things away and then are caught unawares. Look at the US congress and the Republican party in the late 1930’s, even when Hitler invaded Poland for God’s sake, it took Pearl Harbor for them to acknowledge the obvious. So we can’t expect more today. That’s the way comfortable politicians are. So what is to be done?

The geriatric and constitutionally cautious bumps on the log have to move to the rear seats and make room for the active, alert, dynamic crowd. The leadership won’t move, let them stay where they are. We need to form a Resistance Council.

A Resistance Council will be self-creating. The vibrant leaders need to form it themselves, and not wait for anyone’s permission, just declare themselves the Resistance Council, devoted to active resistance. They will try to educate the public in an organized, persuasive way. They will hold regular teach-in sessions, in a venue more elevated than the steps of the Capitol — hire a hall, if needs be. Hire professional media people, and get top people to volunteer, to do it right, the way the J6 Committee did, but not taking the time J6 could — we need to fly into action right away. And they will put private and public pressure on our congressional leaders to resist — to gum up the works in an organized fashion, to embarrass our Republican opponents and even our Democratic static friends into moving the congress into true opposition.

The leaders of the Resistance Council to actually lead. They will mobilize and organize all those who want to be part of the Resistance, while keeping the council leadership small enough to handle.

Who are the obvious candidates for membership in the leadership of the Resistance Council? Here are some starting names: AOC, Chris Murphy, Pete Buttigieg, Jamie Raskin, Adam Kinzinger, Bernie Sanders, Reuben Gallego, Jasmine Crockett. This council would plan the PR campaign and plan the congressional actions. They would raise money for legal support against actions the Trump administration will bring, and solicit lawyers to set up pro bono legal defense councils for all the charges Trump will bring.

The states will also need to organize themselves to resist — just today the Governor of Maine challenged Trump to his face, and he tried to bully her down — that’s who he is, would-be mobster. J.B. Pritzker has put himself forward. The Governors and state AG’s should start their own council and coordinate with the congressional Resistance Council. We need a whole bunch of Resistance Councils.

If it’s The War To Save The Republic, we have to act like it. Bring it on. Recognize it. Don’t run away from it. Organize and win. And keep it focused. It’s not just the liberals, although they are the ones I mentioned by name. There will be many others.

This is one fight that has to be won. And to win, it has to be organized. And to be organized, the let’s-wait crowd and the we-don’t-have-any-power crowd have to leave the stage and let the active ones come to the fore.

Budd Shenkin

Evil and Dumb, How Do We Spell The Name?

‪ Trump is so dumb he thinks the game is still making deals and making money (which he actually never could do.) So he joins Russia to shakedown Ukraine - Russia gets control and USA (and prob Trump privately) get rare earths. And he expects to be celebrated for a Mafia play. He thinks it's all money. ‪ We don't say "evil" much anymore; we clean it up with the more clinical "sociopathic." Which is fine, except I'd add also "psychopathic." But maybe "stupid, evil, very cruel" covers it well. But whatever terms we use, we need to act and resist. buddshenkin.blogspot.com/2025/02/will...

Doctors, Mothers And Daughters, Death and Caring, Writing

This essay is also available at: https://medium.com/@buddshenkin/mothers-and-daughters-doctors-and-death-4be81ebf460f

This isn’t a confession of matricide, but technically speaking, I did kill my mom.

Both JAMA and the New England Journal of Medicine have one 1,200 word personal essay per issue. I used to avoid them. I thought, probably unfairly, that they were written by stuffy older men dispensing what they considered their wisdom, as some of my self-satisfied Harvard Medical School (HMS) teachers used to do. I think that opinion said more about me than it did about them. It also reflected the press of time and the relentless appearance of the journals in the mail every week. You took the journals in the hope that you wouldn't miss important things. You also hoped that each issue had nothing important so you could accomplish your self-assigned task expeditiously and just discard it – triaging limited time.

But that has changed. I still hope for articles without interest so I can clear the kitchen table more easily. Accomplishing tasks quickly will probably be a life-constant until I die – well, that's hopeful, isn't it? Still functional until the very end? Here's hoping. But now, instead of dismissing the essay, I look forward to them. I know that I have changed, but have the articles changed? Maybe. For one thing, a lot of them are now written by women. Women in medicine! Thank God for the women in medicine! Like it or not, women write differently from men, because like it or not, women are different from men. Talk about adding needed balance. Every patient should have a choice between a woman or a man for their doctor, because they're just different, not all the time, but lots of times. And we medical readers should have the same choice.

So in this current NEJM issue, Stanford woman neurologist and palliative care researcher , Hannah Kirsch, writes about killing her mother. See My Mother's Choices – https://www.nejm.org/doi/full/10.1056/NEJMp2410639. She a hell of a writer, this one. So many of the 1,200 words writers now are really good – the liberal arts persist in medicine. Good words, punchy, each sentence counts. Great introductory sentence: This isn’t a confession of matricide, but technically speaking, I did kill my mom. Men can and do write like that, of course, and sensibilities are not segregated by sex. But one thing is segregated by sex. That thing is the relationship between mother and daughter.

There's just something about that relationship that's different. I read two books in the last couple of years that if you haven't read, you should, especially since they're not only great, they're short. One is Annie Ernaux's remembrance of her mother on the occasion of her death, A Woman's Story. She is raised by her ambitious mother in the working class of Yvetot, Normandy. Annie replaces a sister who died at age six. What is the effect of replacement? We don't know, but it affects all of them. We'll try again. They're trying again with me. Most of us carry the burden of expectations, they propel us forward, they give us a sense of mission that comes not just from us. I titled the book that one of my characters wrote in my unpublishable French novel, “Amour, Cadeau ou Fardeau ?” Love, gift or burden? My character, Juliette, means it in romantic love, but clearly, that's not the only love nor the only gift nor the only burden. Annie turns out to be very, very smart, and grows up to write books I love, books of genius, books worthy of the 2022 Nobel Prize for literature. But along the way, inevitably, her growth and excellence, fueled by her mother, draws her away from her mother. Her sensibilities change. Her social class changes. Her interests widen. Her conversation is at a higher level. Annie is bored at the narrow working class conversation around the family table when she returns from Rouen or other place of residence. It is the gulf her mother hopes for and then suffers from. Annie is dutiful. After her father dies and Annie is living in eastern France, her mother comes to live with her and her husband and her two sons. Grandmother takes care of the grandsons, meets some people, and it is one of the happiest times of her life, maybe her happiest time. When Annie moves to an anonymous Paris suburb around the Boulevard Périphérique, known as the Périph, that time is over. There are no friends to make here. So her mother moves away, back to Yvetot I think, and then she dies of Alzheimer's, and Annie reevaluates the long course of mother-daughter love. The closeness, the identification, the irritations, the impatience, the guilt, the duties, the rupture. Growing up. Love is such a mixture of contending feelings sometimes. Father and sons have it, sure, but not like mothers and daughters, I think.

The other book you have to read is Simone de Beauvoir's A Very Easy Death, another short book that is easily read. “Easy Death” is what someone says in all sincerity after her mom dies, but after what we've read, we understand it as an ironic title. I've come to think – is any death “easy?”

Simone gets more of her ambition from her rather unsuccessful father, I think, and from her inborn indomitable will – as a toddler she lies on her back on the floor and screams from frustration and no one can stop her – than from her very religious mother who easily accepts her place in a man's bourgeois world. When Simone loses her faith, she becomes a lost soul to her mother's anguish. When she grows into her life as perhaps the most notable woman of the 20th century – I think I love Simone – I think her mother gradually accepts her new status, but the bitterness of the gulf remains. I have to read the second volume of her memoir to really know what happened to them, but the first volume is striking and even lacerating. It must be hard to talk when you come to such different stations in life. But then her mother gets cancer and is going to die, and gradually does just that, Simone and her younger sister Poupette tending to her together. A dying mother, a mother who raised you, who you were so close to, who facilitated your rise in life, and who you left behind perhaps bitterly, who pissed you off, but a relationship of love you can't leave behind, it just sneaks around another corner. Her mother is not told she has terminal cancer, the doctors won't listen to slowing down their fruitless pursuit of cure, but then she must accept it even if unspoken. She sits in bed with one arm around Poupette and one arm around Simone and she says, “My girls. That's all I really want, my girls.” And I cry.

So now we have women in medicine, and they can write about their mothers. I heard about this one incident from a friend who hasn't written about it. A woman doctor friend of mine at HMS lost her mother last year to cancer. As her mother got sick, she needed tending to back home in the Southwest.. Their relationship had been fraught, especially as her mom had divorced and become a single mom with all the intimacy with a daughter that that can entail. Do you drop everything to tend to a mother with whom you have had a tenuous relationship? My friend did; she took leave and went back and tend to her mom, she was glad she did, but it was never easy. But she did what a daughter has to do. I'm not sure it brought resolution to their relationship; I suspect it didn't. But she did what was right, and I'm sure she did it with great compassion, because that's who she is.

Hannah's relationship with her mother was similarly fraught, and as part of her reflection, not to say resolution, she writes about the death by assisted suicide, movingly and beautifully. As for all of us who are doctors, when our parents or our wives or our husbands die, we are both daughters and doctors, husbands and doctors, and sometimes we are parents and doctors. Our HMS classmate Gerry Rogell presented us, his HMS classmates, just recently, this very same ambiguity and dilemma when his wife was ill with Covid. We are sons and daughters and husbands wives with special powers. As doctors we struggle with how close to get with our patients, how close we can afford to get, how apart we need to stay. We struggle each in our own way. I wonder if the special power, knowledge, makes it easier or harder. I think it made it easier for me when my wife was sick and dying – I was oriented to the field, and I did adapt to being instructed and leaning on caregivers and nurses, because as a pediatrician, we could all accept that I knew things as a doctor but didn't know things as a child's doctor. In my friend Gerry's case, it was a little harder, because he had to decide whether or not to press for a medical course that he thought might be indicated, and didn't know at that point whether to act as a doctor or a husband, and was tortured by that choice.

But in Hannah's case, dealing with a difficult mother with strong independence needs, just like Annie and Simone and Gerry, was it easier or harder? Actually, it seems to me that it was easier. She knew medical expectations. She knew endpoints. She had seen many courses that patients had taken. She could navigate the mother-daughter relationship with that information giving her perspective. As a doctor she knew how to talk, so instead of rejecting her mother's request instantly as impossible, she takes a minute and says, “What makes you ask that now?” And she continues, until the end, when her mother chooses not to surrender to decay but to choose herself when and how to go, and Hannah mixes the deadly elixir and gives it to her mother to drink.

I never let her, or any of the other people at her deathbed, perceive what roiled between my agonized detachment. I wanted someone else to be in charge, even though I couldn't let go of the iron control of the 'primary caregiver.' I wanted to inhale the dregs of the mixture in the hope of sleeping, not forever, but long enough to resolve the conflict between my personal desires and my professional commitment. I wanted to curl up in her lap, just the two of us in the room, and weep, begging her not to do this, telling her that I need her to tell me I'm her special girl, that I'm scared and need my mom.

And I cry.

Maybe you see why I'm not skipping the little personal essays anymore.

Budd Shenkin

To Thwart A Coup

 My son Peter sent me this podcast from Ezra Klein.

 https://youtu.be/K8QLgLfqh6s

Here is my response:

I agree, this is very good.  Thanks for calling my attention to it.  It's a call to sanity, but I'm still fearful that Trump will have all these powers.  The fork in the road will come when the courts rule against him and he disobeys, which is what he's setting up to do. I don't believe for a moment that he won't defy the courts. Andrew Jackson did it successfully, which led to the Trail of Tears.  Eventually his party petered out, but nowadays, I fear that won't happen.  I fear that partially because the Democrats are so weak and feckless.  They need to reorganize - I give one idea: https://buddshenkin.blogspot.com/2025/02/will-there-be-credible-resistance.html.

If you have a firehose of issues coming down from Trump, you need to respond in an organized way, and defend everything, speak up forcefully, explain and persuade the populace.  They should engage on Ukraine - Trump is now changing sides, making us Russian allies -- Presidential strength is greatest in foreign policy as you know.  The Dems need to address this, need to actively recruit Republicans - ask them if they are ready to support Communists.  This could be a real rift in the Republican party, but because "voters don't care about foreign policy," the uninspired Dems will instead concentrate on egg prices.

I find myself being frustrated with the Dems and even being angry at them.  I think it's because of team sports.   I expect the Cowboys to try to be strong; I don't criticize them for that.  But if the Niners don't mount a credible opposition, I'm frustrated with them for failing us.  Schumer and Jeffries have adopted a strategy of saying, "We have no power!"  They're planning to pin everything on the Republicans.  That's correct in a way, but the optics are awful - how do you inspire people by declaring "We have no power?"  That's why there needs to be a group of excellent, aggressive, eloquent Dems who organize themselves and dare the rest of the party to follow them.

I don't expect anything from the congressional Republicans, actually.  They are less representatives than they are paid agents - they are married to their jobs, their jobs depend on election funding, and with SCOTUS vetoing any election funding reform (SCOTUS bought and paid for by wealthy right wing), congressional Republicans are just paid agents.  But some of them might be embarrassed if they were held up as supporting Russian communists.  Try defending that one.  Or maybe I'm wrong and isolationism would prove to be more popular.

Will the Trump revolution succeed?  Are we really so soft that traditional democracy will be lost?  Will the increasing failures of government under Musk and Trump make people value government more, or will they take it as evidence that government sucks?  There are many forks in the road and that's hard to predict, but I tend to think about quality of leadership.  If strong and decisive leadership does not emerge on the Dem side, then I think our culture can collapse back to the racist past, at least to some extent.  This team is bent on destruction, and destruction is easy, it's building that is hard.  Can the South African apartheid metastasis that we're seeing now actually prove lasting in a US that has come so far since the 60's?  Is all that reversible?  It's hard to think that it is.

I guess in the end I have to be hopeful, to believe that the evolved culture of the US as we experience it where we live will prove durable.  I have to believe that there will be enormous pushback and that Trump and Trumpism will die, sooner or later.  I'm just hoping for sooner.  I'm hoping for leadership to emerge stronger than ever.  I have to believe that leadership will emerge from the states.  If Trump & Co. make the feds weak, then the states will become stronger, and leadership will emerge from there.

But in the end, who knows?

What do you think?  You have a certain reasonableness of levelheadedness that I always find bracing.  I'm so glad you majored in poli-sci.

 

Budd Shenkin

 

Will There Be A Credible Resistance?

 

I think a lot depends on how the Dems can organize themselves in resistance. Leaders must be allowed to emerge. Congressional Dem leadership now is old and abysmal.  They need a War Council, and regular Addresses to the Nation analyzing what's going on, and how it's a coup, an autogolpe, or a revolution, and pointing out in detail what they're doing and how they're lying about it.  

Who can do this?  Buttigieg can explain it, others are eloquent and passionate, but they are all either backbenchers, or sometimes governors.  They need to organize themselves as The Democratic Resistance, and challenge the rest of the Dems to follow and join them, or not.  That would capture the country's attention, give media somewhere to go, and set up for the lawsuits which are already progressing, and most importantly, for 2026 elections.  Each Dem would have to choose, are you an active resister, or not?  Through this, the candidate for the 2028 election, should there be one, would emerge.

What they obviously cannot do is to rely on their current congressional leadership.  Schumer and Jeffries might be effective insiders, but Schumer is an awful public speaker -- reads his remarks into the rostrum -- and Jeffries struggles.  Their task is to hold the Dems together within their chambers; swaying the nation is not in their remit.

Anyway, that's my take.  Even this might not work, because SCOTUS has already been captured, so many other courts (Aileen Cannon, Judge S. in Amarillo, etc.).  This War Council, plus the states, with active AG's and Governors in the blue states, are the last hope.  Popular movements, demonstrations, etc., I would think would only arise with good leadership explaining what is happening and gathering adherents that the people could rally around.  Remember what Allard Lowenstein had to do -- find a candidate.

Budd Shenkin

The Fruits Of Aging

 

As you get old, you accumulate wisdom.

As you get old, you make more mistakes, or continue with the old ones but they get worse.

Which is it?

I think it's both.

It's just like it's always been - you try your best, and try to forgive and get others to forgive your mistakes.

Sometimes it works.

How The World Is Organized -- The Trump Model

 

What is going on with Trump's view of the world? He wants to stop supporting Ukraine, is very iffy on NATO, hasn't said much about Taiwan, but wants to flex on Mexico, Canada, Panama? What's up?

I can't review all the different ways of organizing the world – not my area of expertise – but clearly we have had empires (Rome, China, British), and we have had configurations of independent states with balanced power(Europe after the Council of Vienna). We've had a system of international laws that recognize countries' boundaries and strive not to interfere internally in their affairs (never really respected). We've had a dual-centric world – USSR vs. USA in the Cold War. We've had systems where armed interventions are supposed to be abjured – post WW I. And so on. Some would say the world has always been organized by strict power, and ideas to stop war and rule by recognized rights is most a modern attempt. But as I say, it's not my field.

So, as far as I've been alive, the world has been dominated by the thought that we should have a universally recognized system of laws and avoid wars. At least, that's what I've seen. Now we have challenges to that, as the Chinese seem to say that this so-called system of rights and respect is hypocritical, and just hides the continuation of the long era of Western domination. And now, it seems, we have a new view, probably a view that would be called “realist,” from Trump.

That view seems to be this: We know that Trump has fancied himself a realist of the thuggery of the world. He has idolized gangsters. He thinks it realistic to understand that countries kill people, they just hide it. The states are all hypocritical, Trump thinks, they say one thing and do something else. The words are on the surface, but it's something else beneath.

He liked to hang out at construction sites at his father's buildings. The working class sees power and people being compelled, not cajoled and persuaded. He himself likes to bully. A lot. So, I think he sees the natural order of the world being based on power and ruthlessness. That would mean that strong states bully weak states, especially nearby ones. This leads to a multi-centric world where regional powers dominate their neighborhood. This is an ancient situation, where transportation and communication was none, or months, or years. In those days a regional power would think of themselves as a world power, because their worlds were small. Nowadays, we know better than to think ourselves isolated, but with the threat of nukes keeping world powers at a distance and enforcing limits, no one should really aspire to world domination, but they can aspire to regional domination.

Who is this reminiscent of? Well, that was the world Hitler envisioned. Let the Japanese dominate the East, let the USA dominate the Americas, and let Germany dominate Europe. Hitler couldn't see why others didn't agree. That's also – relevant to Trump – the view of the Mafia. Let one group dominate Buffalo and don't bother them, cooperate when possible. We keep Brooklyn and Queens, let others have New Jersey. We can compete in new areas, like Las Vegas, but we won't threaten the home territories of the other families. And in both these cases, Hitler and the mafia, force is the dominant influence.

So that's the way Trump sees the international organization. That's why he thought Putin's invasion of Ukraine was brilliant. He surely understands Xi's determination to take Taiwan, with Hong Kong already digested. He thinks it's just weak for the US to allow nearby weaker states to be independent – why don't we dominate them the way the USSR dominated Eastern Europe? It's our right, because we're strong. Mutual respect of borders and sovereignty is stupid and weak, to Trump's understanding.

And what do the leaders of these blocs do? They make sure they get themselves rich. Putin is reportedly the richest man in the world. I hear that he has a deal with each oligarch that he, Putin, personally, has a 50% interest in each of their enterprises. That's why Trump idolizes him. Of course! He's the strongest and that's what he deserves. He's due it. That's exactly what Trump thinks he's due. It's the way of the world, the true order, not this made up stuff about mutual respect and ideals. Realism.

So, no mystery. We don't interfere with the way other dominant states rule their area, and we don't care what they do. Human Rights? Gimme a break. That's made up stuff by the Sunday School crowd. Me, I'm a realist, Donald the Realist. He was the strongest in his family and he dominated them, he was the strongest in the Republican field, and now he's the strongest in the country. Don't give me that stuff about right and wrong.

For starters, Donald no doubt wants a 50% personal interest in the Panama Canal, and a 50% interest in each Canadian energy company.

Why not?

Budd Shenkin

Humanistic Care - Defining and Implementing

 
Medicine is supposed to be humane, kind and caring – to be humanistic.  Yet both patients and doctors complain that our current system lacks precisely that quality.  Patients complain that their doctors often don't get to know them well, that when they are sickest they are cared for by strangers in non-patient-centered teams, and that they get lost, neglected, and delayed in a complex system.  Doctors complain about burnout, alienation, even moral injury, as they, too, miss the human connection with patients and regret the systematic obstacles they face.

Two prominent influences for this decline are, ironically, the great advances in Biomedicine (BioM), and the ubiquitous business methods utilized in medical care organizations.  The proliferation of specialists, procedures, and studies has presented organizational challenges, and efforts to achieve systematic efficiency, productivity, and profit have often given short shrift to the necessity of warm human interactions.

The loss of Humanistic Medicine (HM) is not inevitable, but it must be understood if it is to be protected and reintroduced to the system.  First, HM should be defined.  Second, we should examine its composition, to decide if HM is central to the mission of medicine, or if it is only a frill that might as well be neglected.  And third, we should define some necessary steps to implement HM in practice.

Definition

The standard definitions of HM cite the actions of the doctor as the central factor.  One example: “the physician’s attitudes and actions that demonstrate interest in and respect for the patient and that address the patient’s concerns and values. These generally are related to patients’ psychological, social, and spiritual domains.”  Another source cites the “Three C's”: “(HM's) main components(are) 'comprehension' of the patient's narrative and importantly – emotions; leading to 'compassion' and a 'commitment' to act trying to help as much as possible.”

These definitions have two shortcomings.  First, they are process-oriented rather than outcome-oriented.  The desired outcome of HM is that the patient should feel known as a specific individual, not a cog in a wheel or as an input, and should feel cared for and cared about.  Second, even though the definitions do well in describing desirable physician HM actions, they are too narrow, because they ignore the contributions of other personnel, and the system of care itself.

A corollary to the outcome definition is also important: the benefits of HM accrue to the givers of care as well as the recipients.  Humans feel great satisfaction in giving to others.  Doctors, other caregivers, and even system planners and managers benefit from treating patients with high-level HM.  In fact, it can give significant meaning to their lives.

The Content and Extent of HM Services

HM is effected both by the organizational system of care and the individuals within the system.  The system's design and functioning let patients know if their needs come first or last.  For instance, are appointments made easily and timely, or (for instance) is a patient with a new cancer diagnosis made to wait in psychological anguish many weeks for a first appointment?  If it is the latter, that system could be accused of HM malpractice.  Likewise, is the length of an appointment tailored to individual needs, or is every patient wedged into the routine average time of a visit?  Is continuity of care respected, and are various specialists and tests all coordinated in a patient-centered way, is there always someone for the patient to turn to for personal help, or are patients left in the lurch?  These are just examples of the myriad of organizational HM factors.  Organizational leaders, system designers, software designers, human relations departments, managers and others are in charge of all these items of HM.  

All service industries have to accommodate customers, but medicine is a special service business.  No other line of business addresses “customers” so intimately, with such emotionally-laden, high-stakes and sometimes complex and dangerous pathways and decisions.  The pressure on patients and clinicians can be immense, as they deal with life, death, disease, disability, anxiety, and anguish.  Patients and their families need to be cared for with an intimate knowledge of their emotions, backgrounds, and beliefs, as the standard definitions point out.  Patients don't just need a reliable sales representative as with other businesses, they need someone whom they can trust with their most precious possession of life and health, someone with deep understanding and compassion and skill and reliability.  Figure One shows why HM is central to the medical mission, not peripheral.  Any system design or educational effort or practitioner neglecting that special responsibility of caring in medicine is in violation of the medicine's central mission, to cure when possible, but to care always.

Requirements to Implement HM Services

If HM has weakened, which seems to be the consensus, what is needed to strengthen it?  Most importantly, the priority of HM in health care organizations and medical schools should be promoted  to stand beside profit and BioM excellence as an equal top priority.  This takes leadership, but it also demands support in the ranks, most prominently from doctors, other caregivers, and patients, those who experience HM most directly.

Instead of the current lip service, this high priority must lead to sustained attention and devotion of resources.  Managers must be given the task of maximizing HM to the extent possible.  They must learn to implement HM-friendly conditions, developing processes that are more patient-centered and less factory-like.  Electronic communications should be an asset for HM, not an additional barrier.  Measures of HM must be developed, even if they are based on process rather than outcome, so that they can stand beside the current measures of productivity, financial profit and RVUs, both of which notoriously ignore HM, and in fact classify time spent on HM as waste.  Business management techniques are valuable, but the goals of medicine must be recognized as different from typical businesses.

Likewise, medical education must specifically target HM teaching, especially in clinical training, where HM teaching has often been assumed rather than specifically included, and where HM has often met the counterforce of an “informal curriculum” that discounts HM.  BioM is relentlessly taught and tested, appropriately, but HM needs its own emphasis in imaginative ways that suit it, and take it out of the shadows.  Every medical school typically has many HM-friendly personnel; they need to be mobilized into active contributors to a coherent HM effort.

Finally, incentives for practicing strong HM need to be harnessed.  Inherent idealism in students and practicing doctors is considerable, but in addition to idealism, HM productivity and excellence in teachers, practitioners, care teams, and managers needs to be recognized, celebrated, and paid well.  

Conclusion

While it is complex, HM is definable.  While BioM is of ultimate importance in curing, the caring provided by HM is a worthy partner.  Humanistic care is not a frill, it is essential to the medical mission.  

All organizational change is difficult, and strengthening HM will be no different.  But since the basic elements of HM are known, the task is mostly one of reengineering rather than of basic research.  With a readjustment of priorities and with devoted effort, it should be well within our current capabilities to re-humanize medicine.  Where there's a will, there's a way.

 

 

i. Gilsdorf, JR. No one in charge. N Engl J Med 2024;391:974-5.

ii. Dean W, Morris D, Llorca P-M, et al. Moral injury and the global health workforce crisis. N Engl J Med 2024;391:782-5.

iii.     Branch WT, Kern D, Haidet, et al. Teaching the human dimensions of care in clinical settings. JAMA 2001;286;1067-74.

iv.     Schattner A. The essence of humanistic medicine.  QJM: An International Journal of Medicine 2020;113; 3-4.

v. Hundert EM, Hafferty F, Christakis D. Characteristics of the informal curriculum and trainees ethical choices.  Acad Med 1996; 71; 624-42.

	Challenges to Caregivers in Humanistic Medicine
Patient relations
	Doctor-Patient Relationship	Understand choices available, apply which model is appropriate to each situation and patient.
	Role of the doctor	Knowing how to integrate professional demeanor with personal and professional authenticity
	Doctor flexibility	Understanding the history of relational expectations, different national and cultural expectations, and how relationship expectations have changed over time, with patient independence emergent, and paternalism in decline
	Doctor flexibility	Understanding how to adopt different styles for short-term and long-term patient relationships
	Understanding patient needs	Understanding the power of projection, how patients need to feel they are in good hands
	Patient variability	Understanding both the commonality of patients, but the differences that culture and finances and other circumstances present
	Communication	Knowing how to elicit and communicate information and feelings effectively and sensitively
	Emotional distance	Be conscious of what the distance is for each patient and family, know how to be close and available, but still objective, know your own needs and capacities.
	Empathy	Know how to be truly empathetic from one’s own experience and practice, and know how to communicate it.
	Caring for	Be conscious of and know how to fulfill patient need for emotional support, and for continuing positive monitoring of medical progress and offer guidance.
	Boundaries	Understand and adhere to boundaries of patient relations
	Power relationship	Understanding the power relations between doctor and patients, and not using it inappropriately
	Respect	Treating patients with respect, as a patient with disease, not “the thyroid in 208,” not “a fascinoma”
	Navigation of difficulties	Knowing how to handle difficult and provocative patients. Understanding clinician anger when patients don’t fulfill sick role properly.
Severe Disease
	Deliver bad news	Knowing how to and when to give bad news, such as a diagnosis of serious disease, returning cancer, untreatable condition.
	Caring for seriously ill patients	Knowing how not to shy away from very sick people
	Organizing clinicians	Knowing how to integrate into present care physicians and caregivers who have treated the patient in the past, especially PCPs.  Coordinating specialists with consistent voice for patients
	Organizing team care for seriously ill patients	Assigning roles, appreciating all team members, coordinating actions, sharing understanding of actions and goals
	Switching from cure to care only	Knowing when to stop treatment and switch to palliative care, involving and listening to the patient and family, but showing leadership
	Caring for “incurable” patients	Knowing what to do when there is nothing to be done, how to be there with the patient
	Cooperate with family in terminal disease	Knowing how to comfort families of the dying
	Confronting death	Knowing how to process death, the family's feelings and your own - understanding and accepting the natural course of life and death
	Making sense of serious illness	Knowing how to employ narrative medicine to help give share a meaning for the patient’s life
	Making sense of serious illness	Knowing how to adapt to belief systems and values of the patient to put life and death in perspective

 

The Heart of Scientific Progress

It's a little crinkly as a photo, but this is the image of my article, taken from the post a few days ago, as published in the East Bay Times/San Jose Mercury.

 

 

And also the on-line version:

Opinion: The heart of scientific progress beats for all of us

It takes money, time and patience, but constant investment in medical science helps millions of people to thrive

(With permission from David Levine)

An image from a fluoroscopy shows, to the left of center, two blockages in David Levine’s right coronary artery.

By Budd Shenkin

UPDATED: January 9, 2025 at 5:44 AM PST

I’m in my 80s now, so I remember what life was like in the 1940s and 1950s. In those days, heart attacks hung like the Sword of Damocles.

They took the lives of so many, and few knew what to do about it. Several times, neighbors called my dad, a neurosurgeon, to their houses, only for him to find someone dead in bed. At the news of the death of another friend, Joey, who died at age 39, my parents could only shake their heads.

Philanthropist Mary Lasker and U.S. Sen. Lister Hill of Alabama took the long view. Seeing the health problems that beset America but also seeing the beginnings of medical science progress, in 1955 they persuaded the federal government to vastly expand the National Institutes of Health, targeting research on heart disease, cancer and stroke, the major killers of Americans. Over the following decades, the NIH and other agencies have spent billions of dollars on in-house research and on grants to hospital and university researchers. Amazing progress has ensued, benefiting us all.

Here is one personal example. In early December, my next-door neighbor David Levine, a 71-year-old law professor in apparently good health, felt some discomfort in his upper back. He wisely visited his primary care doctor. Suspicious of a heart problem, she sent him to cardiac stress testing.

The stress testing was abnormal, which led to scheduling an angiogram promptly. As David nervously anticipated his angiogram, I reassured that this is now just routine, the welcome medical situation of “another one of these” rather than the dreaded, “Hmm, this is challenging.”

The angiogram would have seemed otherworldly to my parents’ generation. The cardiology team made a small puncture of David’s right radial artery and threaded a catheter up into his coronary arteries. They were surprised to find that the right anterior descending coronary artery was 90% blocked in two adjacent spots, a very dangerous condition.

They inserted stents and transformed the arteries from 90% blocked to 0% blocked in just a few minutes. David was under waking sedation for the 90-minute procedure, answering questions from the surgical team and watching continuous images of his beating heart on a monitor as they operated.

After the procedure, the interventional cardiologist told David he was only a few months from a heart attack — the 1950s scenario. Instead, just four hours later, David was on his way home to resume his family and professional life. We laughed together at the wonder of it all.

David’s story is repeated daily for people in every walk of life. Did Lasker and Hill dare to imagine this future? We must be grateful to them and to the researchers and practitioners who developed such techniques, the professionals who care for us, and to the leaders who continually invested on behalf of subsequent generations.

Was it too expensive? We can ponder government spending priorities, but as Lasker said, “If you think research is expensive, try disease.” It takes money, time and patience, but look at the results for millions of people.

With a new presidential administration assuming power in Washington, we hope that they honor the vision of Lasker and Hill and keep investing in scientific progress. Let them not be seduced by the vision of headlines trumpeting mindless “efficiency” and claims of “money saved.”

Let’s hope we won’t be led by those who know the price of everything and the value of nothing. What could be of higher value, after all, than what we have just experienced?

Dr. Budd Shenkin is a physician in the East Bay and a graduate of the Goldman School of Public Policy at UC Berkeley, where he is a member of the board of advisers.

Life And Care Of Heart Disease - A Little Perspective

 

 

                                                       David Levine - today

 

Here's how things have changed.

I was born in 1941, the eldest of four. So I remember the late 1940's somewhat, and the 1950's very well. In those days people married and had kids earlier than now. My Dad was born in 1915, my Mom in 1917, so they were parents at ages 26 and 24, and parents of four at ages 34 and 32. So I remember things they said probably by the time I was 10, and they were like 36 and 34.

Although the modern medical era had been born before I was, medicine wasn't very advanced compared to now. The invention/discovery of penicillin was an early sign of miracles to come when I was a kid. We were down the shore in Beach Haven, NJ, for the summer – my Mom took care of us kids and my Dad came down on weekends I stepped on some glass, probably, in Little Egg Harbor Bay and cut my foot, although I was convinced that a crab had bitten me. We got it sewed up by a local doctor. Was that the time it got infected, or was that from some other accident? I don't know. But whichever time it was, I got a suppurating infection of my foot.

In former days, that infection could have been catastrophic. But now we lived in the penicillin era. I was taken back to Philadelphia, I'm pretty sure it was to the Graduate Hospital where my Dad, a neurosurgeon, often had patients, and I was treated with penicillin. Those weren't the days when they gave you pills, or when you got your intravenous meds by IV's, and it wasn't even the time when you got spaced out doses of penicillin with lidocaine that lasted 12 hours or more. Nope, it was the era of four doses a day by intramuscular injection, and it hurt like hell, as I remember it. My Mom left the other kids at Beach Haven, under the care of whom I don't know, and stayed with me for the few days it took for the infection to be cured. All this, for a foot infection of a wound.

The shots hurt, so when the nurse showed up, I cried and protested. Then my mother got herself together and talked to me quietly and convincingly, and said I'd have to take the shots anyway no matter what I did, so why didn't I try to be brave and not protest? The next time the nurse came in I smiled a big false smile and turned over on my belly to get my shot in the ass. The nurse said, “What's got into him?” She gave me the shot and I absorbed the pain quietly. Amazing what my mom could do when she put her mind to it.

But what modern medicine hadn't gotten around to yet was heart disease. There was a lot of smoking, and who knew about cholesterol? I remember my parents saying, when something came up about heart attacks, I guess, “Remember Joe Ziggerman?” And they shook their heads. I asked what happened to him and they said that he “dropped dead” of a heart attack at age 39. “39,” they said. 39.

We lived at a house in West Philly until I was in 8^th grade, in a semi-detached house, 422 South 47^th Street, just down from the corner of 47^th and Osage. Our front door opened onto a little landing that we shared with the house next to ours, where the Barkan's lived. Ben Barkan was a red-headed lawyer of Democratic persuasion, and they had two kids I remember, it might have been three. Ben was a well-built man, his wife Sylvia was an open-hearted and expressive woman with dark hair who hated Republicans. It was the McCarthy era, and tensions were high. I think they were ADA members, Americans for Democratic Action. Ben was also a tennis player, although we never played with them. It must have been after we moved to Wynnewood in Lower Merion Township in the suburbs when I heard that Ben had died while serving in a tennis game, dropped dead of a heart attack. I remember one dinner party at my parents' house in Wynnewood, I'm pretty sure it was when I was home from my freshman year at Harvard, and my parents had invited Sylvia, who was there alone, a widow.

Just over a block away, at 46^th and Osage, lived our close friends, the Levins. Father and mother were Herb – another liberal lawyer, although one more practical than Ben – and Beck (Rebecca) and their three children, Bob and Susie and Larry. I don't know when it was that Herb had his heart attack, but I know it was after Susie had died of leukemia, which would have been fairly readily treated if she had had it today, because treating childhood leukemia is one of the great achievements of modern medicine. When Herb had his attack they called my Dad and he took Herb down to Penn, not too far away, and Dad protected him from the residents as best he could in the ER. Dad said that the resident kept yelling at Herb, “What's your name?” Dad said, “I'll tell you his name, just treat him.” Of course they didn't have much to treat him with then, maybe give him some oxygen. But thank God he survived. Still, that's what lurked in those days.

When we moved out to Wynnewood, we lived in a new subdivision of what had been a rather large estate a block down from Montgomery Avenue and North Wynnewood Avenue. (Wynnewood, I remember from the plaques, “Named for Thomas Wynne, physician to William Penn, and first Speaker of the First Pennsylvania Assembly.” At least that's how I remember it.) Our little subdivision had Jews, all Jews, in the WASPy Main Line that had already seen Jews in Merion, but now had come to Wynnewood. I remember sitting with my parents in the real estate office as they were buying our house, the Jewish developer telling Mom and Dad the names of the other families who had moved in – Herb Lipshutz, the plastic surgeon, the Simon's, the Lowe's, the London's, others. The real estate agent who was handling all the sales commented, “Where are the O'Connor's and the Kelly's?” The developer and buyers turned their heads toward him and acknowledged the comment with polite and tentative laughter. Neighborhoods change, it can seem like an invasion, I guess, but for real estate agents, it's just business.

So we moved in and Mom and Dad stopped paying four tuitions to Friends' Central School and sent us to the very good public schools of Lower Merion. We made friends with our neighbors. One night my Dad got a call from our next door neighbors, the Simon's, and Dad went and found the father of the family dead in his bed from a heart attack. I was gone to college at the time. Somewhat later they got a call at night and Ed London was dead in his bed as well.

In the 1950's the NIH was formed, on the initiative of Mary Lasker and Democratic Senator Lister Hill of Alabama – a monumental achievement of lobbying a government to do the right thing. In the coming decades, national health policy targeted heart disease, cancer, and stroke as the big killers. Billions of dollars went into direct governmental expenditures and grants to university researchers. We are now 60 or 70 years out from that beginning. It is the grandchildren of the generation that started the effort who are benefitting. They say that democratic governments can't stick to something, and that government is ineffective. There are those of us who differ with this diagnosis.

It's true that our national expenditures for health care underemphasize primary care and overemphasize specialty care. But it isn't true that we are getting nothing for our money. Herb's son Bob, my close friend, had severe heart attacks ten years ago, received heroic care including several days of hypothermia, and is alive and very well today. If he had suffered from his heart disease at the time of his father's illness, he would not be alive and well today. The progress has been immense. See his great book, I Will Keep You Alive, available from author.

Then there is what happened this week. On Sunday, my next door neighbor for over thirty years, David Levine, law professor at UC College of Law in San Francisco, came over to show me the documents from his cardiac stress test. He had had some discomfort at the beginning of December and had made the good decision to see his new primary care doctor. She was suspicious of something being quite right with his heart and ordered cardiac stress testing. The stress test revealed an abnormality with the S-T segment of the EKG and she ordered a cardiac angiogram to be performed the following Thursday. I looked at the report and explained some of the terms and findings with David. Doctor's don't have the time and the relationships with patients to do an adequate job with explaining, and it takes repetition anyway, so having a doctor friend next door is a good thing. My Dad always said, each generation of a family should have a doctor, to protect the family from all the crap that can go on medically.

I reassured David that what they were going to do was not dangerous, and in fact was to be welcomed. He was nervous and I told him that of course he will be nervous, but that I wasn't, because it would be routine. What we always want to be is “another one of that;” never “something interesting.” Yesterday he took Lyft to be at the hospital at 5 AM to be the first case of the day. At 7:45 AM I took his wife Joanna out to the hospital to sit and wait for him; another friend came a couple of hours later to sit with her and to take him home after I left. The procedure found a right anterior descending coronary artery 90% blocked in two adjacent spots, and the interventional cardiologist inserted stents that took the arteries from 90% blocked to 0% blocked. He told David that he was surprised to find the arteries so compromised, and the odds were that within a couple of months David would have had a heart attack. David was given waking sedation for the 90 minute procedure and could watch the image of the operation on a monitor if he craned his neck. It was all done through a small incision in his right wrist that took the catheter up the radial artery to the heart. David was just here today, just over 24 hours after the procedure, to tell me about it.

Ladies and gentlemen, this is Star Trek medicine. Who'd a thunk it? How is this possible? From premature deaths with little or no warning, to early detection and preventive procedures and a smiling man with no residua who will be fine.

In the midst of valid medical discontent, it's helpful to have some perspective.

 

Budd Shenkin