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

Something Remarkable Happened Humanistically In Our Class

Something remarkable happened last Wednesday afternoon.

As I think I've written before, our Harvard Medical School Class of 1967 has experienced a rebirth of our comradeship in the last couple of years. After our 55th reunion – which I didn't attend because of the death of my wife just a couple of months before, and I wasn't ready – several of my classmates decided to use that great new technology, Zoom, to have regular meetings of our class. We have always been a cohesive class, helped by the set-up of our beginning at HMS – living and eating together at Vanderbilt Hall for the first two years, having so many classes and experiences together, being relatively small at maybe 100 or so until we got an influx of Dartmouth students for year three. So as the reunion rekindled the connections, Zooming seemed like a natural thing.

Karl Singer, Bob Holmes, and Phil Landrigan put it together as a monthly event, centered around presentations from our classmates on their own scientific interests (sodium depletion in long distance runners) or their medical experiences (Vitamin A supplementation to poor areas of the globe that has saved the sight and lives of millions) or more recently personal interests and events (part-ownership of a minor league baseball team, a session on our members' experiences serving in the military during the Vietnam War, and upcoming a session on what women of our class have experienced as women in medicine.) Other presentations were from experts outside our class, usually from HMS (gender affirming care.) All the sessions start with chit-chat among us. Attendance has been generally from 15 to 30.

In late 2022 I suggested a presentation on Alzheimer's Disease. My wife had just died of it after a very long course, and I had read a book by Harvard professor Arthur Kleinman about his own experience when his wife suffered and then died from the disease – The Soul of Caring. (See my blog article on Arthur and the book here.) Arthur made his presentation to the class and I added a few words myself, and then something remarkable happened – everyone on the Zoom call was energized to reflect themselves on how they had experienced frustration with the lack of humanistic care in our system, both as doctors and patients. It was a very moving session. Sensing this common interest, I contacted Arthur wondering what we could do as a class to promote humanistic care at HMS. He referred me to a class-organizing activist in community medicine, second year student Eana Meng, and one thing led to another and we established a Humanistic Medicine Initiative (HMI) for our Class of 1967. We have a working group of 14 – 2 students, 4 faculty, and 8 HMS 1967 class members. We have had a couple of notable triumphs. We held a HMI dinner meeting at the Harvard Club of Boston, with 6 HMS 1967 alumni, 4 faculty, and 10 students, which was illuminating, energizing, and a lot of fun. We came up with a new definition of Humanistic Medicine. Under the leadership of faculty member Kathe Miller, we recorded a video, entitled “If I Knew Then What I Know Now,” for incoming first year students, where Kathe got 13 of us to sit for her to record our advice to the incoming students. The advice was wide-ranging, but most of it centered on humanistic topics, how to care both for patients and for the students themselves. In addition, HMI working group member George Lewinnek published a book he had been wanting to write on advice for young doctors, with a distinct humanistic medicine bent.

We have also had a remarkable incidence of synchronicity. In our search for how we could help the students best, Eana and her classmates centered on their desire for mentors. They wanted to connect with our class to see what wisdom they could glean. I told Eana I wasn't sure about “wisdom,” but I was sure we had lots of experience to share. Coincidentally, Andrea Schwartz, the head of the Aging and End of Life Care Theme at HMS, and her team including student Micayla Flores who also had come to our HMI dinner at the Harvard Club, were thinking of alumni mentorship at the same time, though with a different angle. They thought that if they could connect students with alumni to discuss how aging was going for them, and how they had experienced their careers and their lives, that might grab the students' attention to their own subject of gerontology. It was really quite an imaginative leap. And at the same time, UC San Francisco gerontologist Louise Aronson was President of the HMS Alumni Association, and she was looking for a way to get alumni involved with the school and with mentoring. It's like there were four different avenues (students, HMS 1967, the Aging Theme, and Alumni Association) all heading to a common interchange and crashing into each other, in a good way.

So last semester, 6 HMS 1967 alumni mentored present HMS students, and it went great. This year, all the HMS Class of 2028 are required to have an alumni mentor for four sessions. So far, it seems to be going great. There is great enthusiasm among all the ranks of alumni, and especially so, it seems, in our Class of 1967.

All during the year, as we met for our HMS Class of 1967 Zoom sessions, we updated our class on what the HMI was doing. It was on everyone's mind. There were many questions and observations. Many people wanted to make financial contributions for HMI at HMS. We have clearly become a class centered on humanistic medicine, it seems.

Gerry's Presentation

And then, last Wednesday, the remarkable thing that I'm referring to in this post happened. Our classmate Gerry Rogell, eminent ophthalmologist from the DC area, wanted to present the case of his wife's Covid, and the medical problems that ensued from it. He introduced his presentation by saying that he had had difficulties with her care, and didn't have anyone or any group to discuss it with, that others had had more difficulty with family illnesses than he had and that he feared he would appear self-indulgent and callous to talk to Diane's illness with them. But he knew that if he presented it here, to his HMS 1967 classmates on Zoom, that we would understand, and that we would be sympathetic. In other words, he trusted us to be caring. And he knew that, as doctors, we would all understand in a way that only fellow doctors can.

What happened was that, despite all the precautions they had taken, toward the end of the pandemic, Gerry and Diane had finally contracted Covid. He got off light but she didn't, she got what seems to be an autoimmune encephalitic reaction to Covid that exacerbated a pre-existing neurologic condition very severely, and he had to care for her through hospitalization, rehab facilities, home care, dealing with doctors and nurses, and having to cope in ways that he hadn't before. He thought her medical care had been good overall, but there had been one untoward incident when Diane was ready for discharge but the doctor had done early rounds and left before Gerry got there, and Gerry wanted to talk to him about possibly tapering steroids instead of just stopping them cold, and what complications to look for, and the nurse put her foot down and wouldn't contact the doctor. Gerry was in a tough spot, being both a caring husband and a knowledgeable doctor, and wanting to be cooperative and respectful as a patient should be, but also wanting to serve his wife's best interests as he understood them as a doctor. In the end he cooperated and they left without discussing the case with the neurologist, but then Diane had a stroke. Would tapering steroids have prevented that? Unknowable, but Gerry was understandably pissed and felt that he had let Diane down by not insisting. He complained to the hospital about the nurse's obstruction and got back a letter defending the nurse and the hospital. Gerry felt dissed and is still pissed.

Diane is still debilitated from the post-Covid events. She can't walk unaided, and her understanding and decision-making are compromised. They hope to move from their home to an institution for older people in New Hampshire, but Gerry is unsure if they can prove Diane's status as able to live independently, which is a requirement. Our society's provisions for these cases is not terrific. People are left to cope in ways that are uncomfortable. Just when their situation is most impaired, they are called upon to make decisions and provisions and it's very hard.

After Gerry finished with his story, our class commented. Everyone was warm and supportive. Everyone told Gerry he should not be beating himself up about failing her, because he had not. He had done and was doing a fabulous job. We all realized how we are in the same boat, how we too are coping with a defective system of care, and there are always some bad actors in the system. We are all trapped in our time of aging, if the 60's and 70's were bearable, the 80's threaten not to be. I told Gerry that what he had gone through, and was still going through, was a trauma, and he needs to think of it in those terms. We get married, and we don't know what will happen, but we know that something will, and the key is, will we meet the moment? I felt I did meet the moment with my wife, and that was comforting to me. Larry Kadish and George Lewinnek and I all emphasized that he was meeting the moment with Diane, exceptionally so. I said, You are a really good person. We can't save them, but we can help. I welcomed him to what I called the worst club in the world. Polly Walker said she remembered when she and Gerry were bicycling together and he told her he was going to marry Diane. Not that long ago, really, or maybe really long ago, I don't know. Judy Chused offered, in addition to observing that when things go wrong we always look back and say “what if,” that her internist daughter is also the CIO of the hospital in question where the nurse had obstructed Gerry from contacting Diane's neurologist, and where the hospital had callously informed Gerry that everything they had done was right, and the Judy would most certainly be bringing the case up to her daughter. Larry Kadish, formerly Medical Director of a major hospital for many years, someone who understands hospital procedures well, offered that contacting the Joint Commission directly would certainly get results.

Most eloquently, psychiatrist Ed Bayard told of his coping with the long illness of his wife, who finally died just this August. He noted that the long illness brought them together in a way that was almost unimaginable. It's hard to say these things have silver linings, but they do prove and reaffirm love and caring, and that's not nothing. We record all these Zoom sessions, but wouldn't you know it, the recording function failed just before Ed's pièce de résistance. Maybe we'll be able to get him to reiterate it, because his contribution was really magnificent.

I think that a meta-comment I made was also important. I noted that he had said at the outset that he was turning to us because he knew he could trust us to understand, to be kind, to be caring, and to give him support – not in those words, but that is what he meant. We are his class, and that means something. Gerry agreed. He talked about his comfort with this community that we have, that we have created.

One of the strengths of our community is that we are all both doctors and spouses, which is a tricky situation. We try to be spouses first, but we can't help using our medical reasoning, and it actually does make a difference many times. But it's hard being both patient spouse and doctor. Do you insist on seeing the doctor when you have been discharged with insufficient discussion? As a patient, maybe you give way. As a doctor, maybe you insist. It's a dilemma frequently noted in essays in JAMA and NEJM by those who have been placed in this situation. Gerry knew that we would understand the dilemma better than any other group.

Would this session have happened the way it did if we hadn't done all the work we have done on humanistic medicine? I don't think so. It has brought our whole class together. We have discussed it, recognized it, tried to help the current undergraduates with it, tried to help HMS with it. We have a common understanding. George Lewinnek emailed me after the session that I should be proud that the HMI has really worked. I think we should all be proud, because so many of us have done this together, not least George.

Our class gestated medically together. We lived, ate, and studied together. Then we differentiated in different medical pathways, in different areas of the country. But our togetherness formed bonds, and we have reaffirmed those bonds through the wonder of technology. We see each other how we are now, more mature, more experienced, with more yesterdays than tomorrows, with much of our lives played out. We have had our triumphs and our failures and our heartaches, and we know that nobody bats a thousand. But still, possibly, if we work at it, it seems we have each other. And we can treasure our yesterdays and honor them with our todays. And all of us can still learn – indeed, we can't help it. And with our mentoring, we can pass our experience on to our successors, maybe even our wisdom. And wonder of wonders, we can do it together.

I talked to Gerry on the phone after the Zoom meeting, and I know Jeff Newhouse called him as well. He feels so warm and affirmed from the whole experience. I assured him that everyone on the call feels the same way. Who benefits more, the giver or the receiver? Gerry did a service to the whole class, really.

It's all pretty remarkable, all of it.

 

Budd Shenkin

Our Present Wars

Why men and countries strive for dominance, I don't know. But I do know that they do. And I know that at the present moment, struggle for dominance is obvious all around the world. Maybe it always has been. Probably so.

What is Russia doing? Russia has been trying to reassert itself as a great power. Under Putin, their declared objective is to be a great power again; he says that the demise of the Soviet Union is the greatest tragedy of the last century.They have nuclear bombs – acquired with a technology stolen by spies just after WW II, but their own technology was great, as well. They launched Sputnik, after all, in days that they thought they might succeed. They do have military technology and power, but their national economic ability is not great. They are a petro-state. Their ability to achieve dominance relies on their aggressiveness and implacable leadership. And their ability to achieve dominance relies on the wavering will of his opponents. Putin has been trying everything he can think of. Militarily, he asserted dominance over Chechnya, he continues to try to dominate in Africa and the Middle East with troops and money, and he grabbed the Crimea with little more than a peep from the West. Now, he is trying to assert dominance by grabbing as much as he can of the Ukraine, and by demonstrating that there are little or no moral limits to what he will do. If he can't have Ukraine, he will destroy it so that no one else has it, either. And he tries every trick he can muster to influence and undermine the democracies, including spreading misinformation, hacking vital organs of democracies, and up to and including buying the allegiance of an American president and those all around him throughout the country. It's war; it's war.

The overall question is: can an autocracy outlast a democracy? Can a country led by capitalists who listen to money, when all is said and done, stay the course with a country led by those who are not limited by popular opinion. Putin's bet is that democracies will tire. Putin's bet is that democracies are inherently weak, and that dominance is a matter of will, not a matter of economic and moral development of a people.

Clausewitz said that war is the continuation of political fight be other means. That may help to clarify what war is, but it might also help to clarify what politics is as well.

While Russia might be fighting dominance and for repair of a lost glory, China's quest for dominance might not be much different. The history of China is a Middle Kingdom that always viewed itself as not only the center, but the apex of the world. Then their perch was displaced by encroaching Western powers that abased and humiliated China. Then Japan humiliated China as well in WW II. When the Communists beat the Nationalists in 1948, China was excluded from recognition for over 20 years and was one of the poorest countries in the world. After strict communism failed, retaining central planning but introducing capitalist reforms, and maturing of the Chinese government, performed one of the great miracles of the modern world, lifting China from a basket case to a leading economic power, with the end of that growth nowhere in sight.

China can be excused, in its contest for dominance with the West, for being skeptical when those misbehaving countries of the past now claim to be simply looking for justice and fair competition, and express hope that China will simply join the community of nations. They can smile and nod, but the natural will to dominance of nations cannot be concealed. Leaders matter; and just like Putin in Russia, Xi in China has achieved complete dominance internally, and he will go as far as he can internationally. He can see no reason to abide by rules of good behavior, which is actually new behavior for the West. He can see no reason he should not dominate as much in the South China Sea as the United States does in the Caribbean. He took Hong Kong and incorporated and dominated it and wiped out liberalism; he can think of no reason that he shouldn't have Taiwan. He can see no reason to obey rules against theft of intellectual property. He can think of no reason that he should not have hacked into every important choke point of the American economy, ready to squeeze whenever need should arise. Invading Taiwan would be a good time to squeeze. It's war. Wouldn't a soft democracy pay the price of Taiwan – far, far away – to go on with its life?

There are material gains to be had by being dominant, and psychological gains. It is just men who hunger for dominance, or would countries led by women do the same thing? Or is it just humans who group together and elect the most dominant people to lead them, or that these leaders grab the leadership? It would be nice to think that just changing the gender of leaders could make a significant difference – too simple. It must be evolution at work – I don't believe the meek inherit the earth, unless everyone else kills each other.

People have fought for years, and then fought for there being no more fighting. It's hard to think that this will change. There was speculation that the existence of nuclear weapons would eliminate wars because of the possible consequences. Not a chance. As in sports, if there are too many strikeouts or not enough, just change the height of the mound. In war, just adopt a code that there will be no first use and proceed as if they don't exist. Just change the rules so the wars can continue.

I still believe in the old conservative view that it is important to remain strong, although it can also be dangerous – neocons can fuck anything up – imagine their misunderstanding when they said, what's the use of a strong military if you don't use it? “Une chose qui m’humilie profondément est de voir que le génie humain a des limites, quand la bêtise humaine n’en a pas.” — Alexander Dumas (fils) (Translation: One thing that humbles me deeply is to see that human genius has its limits while human stupidity does not.)

The ultimate curse of mankind.

Budd Shenkin

Trump Will Try To Take The Executive Branch The Way Of SCOTUS

 

Here is my current thought, followed by the thoughts and fears of my friend Eric Bernthal, written on the day after the election.

 

What Trump aims to do is this: make of the executive branch what the Republicans have done to SCOTUS. Destroy probity, inject sectarian agenda, destroy expertise, inject disrespect, egoism over beneficence, destruction over creation, out with the good people and in with the bad.

Trump is essentially destructive, zero-sum thinking, cruel, crude, and barbaric.  But aside from those charming characteristics, the structure of government is in danger, as many have opined.  The only remaining guardrails are the Congress - I have hopes for some traditional Republicans rejecting some nominees, for Mitch McConnell to be something of a leader in opposition to MAGA, and for the traditional partnership of congressional committees and the elements of government that they relate to forming a braking influence on destruction.  It's also possible that the permanent government will resist their being purged.  But we're really at the last ditch her of Federal guardrails.

I think the states will also have a braking influence - the residual guardrail of federalism.  I expect the more Democratic states to relate more closely to each other, pass conforming legislation on environment, guns, and other objectives.

I would also hope that the Democrats would reimagine themselves, although I think there are a lot of retardants on that.  Their operating theory is gerontocracy, that old hands should lead.  Currently, there is a New York Times article saying that Jamie Raskin, age 61, is being encouraged to challenge Jerry Nadler, 78, for ranking member of the Judiciary Committee.  Nadler is feisty and doesn't want to give up control. It's Joe Biden redux.  I doubt Schumer is ready to go either, or the others mentioned in the article, or Richie Neal (Ways and Means,) or many others. 

 

https://www.nytimes.com/2024/11/30/us/politics/democrats-nadler-raskin.html​.

 

Here's what I say to them: Fellas - read the tea leaves.  A party of old people will find it hard to lead a younger country, and although I am reluctant to indulge in identity politics, age has to be considered.  In a word, too many of the Democrats are navel gazing.  New ideas usually don't flow from a 77 year old.  People are fed up with "old hands."  When it comes to guard rails, will the Democrats form a strong opposition with a real chance to take power, or will they be same-old same-old, tried and failed upward?  Doesn't look so hopeful to me, but maybe the rank and file will realize that the Democrats as currently constituted are not part of the guardrails, but part of the enablers.  It's a little depressing to think that my battle cry has to be, "You never know."

And here is the note written after the election by Bernthal, who had foreseen Trump's election, while I was confident Kamala would win.  What he is outlining is what I refer to above as the SCOTUS-ization of the Executive, in some detail.

I am staggeringly depressed by this — not just Trump's win, but what is likely a total sweep in Washington. I get not a drop of pleasure in saying, "I told you so". 

It's impossible to predict what this will do to the country, but the United States has definitely gotten the President they wanted. Trump improved his support among every demographic group in the country;  he gained tremendously with Latinos and with blue-collar workers who were still traditionally Democratic (until now).  He took all the red states and plenty of blue states. He got plenty of women's votes, too. 

But what actually happens to our government?  I remember when Reagan — and Trump, too, first time around — put real clowns, dangerous and delusional radicals into key positions, and their goal was literally to tear the government down.  It's likely to be that and worse this time. RFK Jr. in charge of health care? Steve Bannon setting national policy?  Stephen Miller as the new Immigration Czar?  Michael Flynn running the military?There will be hyperpartisans — caring about nothing but loyalty to the President — running vastly complex and sophisticated organizations like DOJ, FDA, Interior, Agriculture and so on.  Those agencies and departments will be stripped to the bone.  No one is going to be protecting our air and water; no one is going to keep the food supply safe.    The Supreme Court is now permanently -- at least, for several generations -- removed as the ultimate protector of civil rights and freedoms.  Vast numbers of immigrant families will be rooted out, rounded up, separated from their American citizen children, and sent across the border. Trump's tariff mania is likely to spike widespread job loss here in the US and trigger major inflation.  And the scariest part is to contemplate foreign policy, where Trump's ignorance and inattentiveness will continue to cede the world's markets to China, perhaps irrevocably. Ukraine will either cede the eastern half of its country to Russia or disappear as a country altogether within months. And in the ultimate irony for the moronic Jews who supported Trump, maybe Israel will, too. (How foolish of them to think that Trump actually gives a shit about them, about Israel or about anything other than his self-aggrandizement. As American popular support for Israel continues to dwindle with every Palestinian death,  Iran is likely to bet that Americans won't care if Israel is overrun, and if they don't care, Trump won't care. Unlike Biden, who proclaimed that he is a "lifelong Zionist", Trump really holds no brief for Jews, Israel, or anyone else, beyond himself.

 

Could things get even worse?  Sure. We could have an actual collapse of the core American social contract, the rise of an authoritarian President -- with a Congress afraid to intercede -- giving us soldiers in the streets to quell political dissent, brazen gerrymandering to protect his support forever, acquiescence to vigilantism by the worst of the MAGA crowd (Proud Boys and the like), party loyalty tests for every government job, a complete rollback to the freedoms attained by gay people, a near total ban on immigration (destroying our labor supply and choking off our traditional advantage of having the world's brightest people come here to learn and to work and to innovate in many fields).

 

It might not be that bad. After all, Trump has no real political philosophy (which differentiates him from Hitler) nor an adult's attention span (which differentiates him from everyone else). And he's a moron, not a monster, in his personal views (i.e., he's not a warmonger or lusting for world control).  But the moderates in Congress are gone, the MAGAs are in control, the crazies (Bannon and Miller and Flynn and RFK, JR) have total power.  So why wouldn't this dystopian view happen? Who is there to stop it? 

 

 

Hoping that his is an exaggerated fear, not an understated one.  We have no way of knowing, but the danger of falling into illiberalism is palpable. But we do know this: along with heinous views and aims, Trump and most of his associates are incompetents.  While incompetents can destroy, they have trouble building.  If American cultural norms hold - culture is the ultimate guardrail -- it's quite possible that the two coming years will be hard ones,and destructive ones, but ones that lead to a marked changing of the tide in the 2026 elections, and maybe this election of 2024 will mark the high-water mark of the MAGA insurgents.  

You never know.

 

Budd Shenkin