Sunday, April 21, 2024

Elite College Campuses Erupt - What To Do?


Elite college campuses erupt. Administrators and fund-raisers, known as “presidents,” largely don't know what to do. It's really not that hard, fellas and gals, or it shouldn't be.

Based on what we learned in the 1960's and 70's, what should we think about this? I have a bunch of thoughts, not yet congealed. One thing for sure – don't let it fester. If you do, general reaction will be to elect Nixon and Reagan. Letting it fester, without guiding the flow of the stream and just letting it overflow, would be malpractice.

It's interesting that the outrage over probable war crimes against the Gaza population has quickly metamorphosed into cries to wipe out Israel.  I guess that's the way these things go, especially in the spring.   A lot of Arabs among the university population is probably responsible for a lot of that.  It's par for the course worldwide for many lefty faculty to have delusions of sainthood. Idealism is a good thing. But fanaticism is a bad thing. Enforcing laws can help to tell the difference.

It is such a shame that so many administrators are inept.  They should offer alternative, acceptable ways for students and faculty to express themselves - set up places where they can give their talks, let those come who want to.  Think of their presentations as teach-ins, provide safety for all who come, no to counter-demonstrations, but yes to counter teach-ins.  If there are to be direct person to person confrontations, they need to be supervised. You say universities are about the search for truth? Make it so. Use your words. If they don't work, you'll have to use your monopoly on violence – meaning expulsion, fining, incarceration. Indulgence doesn't stop contagions.

In other words, just saying "not this" is not enough; they have to offer the alternative and say, "not that, but this."  And then enforce it.  Letting things go and hoping they will burn themselves out is stupid; they don't, or at least not for a long time.  The specific penalties and enforcement means can vary.  Certainly, anyone from outside the campus needs to be prosecuted if they make trouble.

While I deeply disagree with the sentiments of the protestors, it is just elementary to say that they need to be able to express themselves.  If they want to practice civil disobedience, they should not be physically harmed, but they should be prosecuted; civil disobedience contemplates this consequence. No blocking of the ordinary business of the university, no canceling of classes, no intimidation. If they feel deeply enough to be expelled and arrested, trusting that they will be proved right by time, they can do that. Personally, I think they will regret it, but then, I was careful not to get arrested in 1969 when I marched in the streets of DC. I don't go nuts.

The incompetent leaders of these universities need to remember that the spread of student uprisings in 1968 obeyed the epidemiologic rules of contagious spread.  Prevention needs to be practiced. When student uprisings occur, reaction is just around the corner.  Although, as a friend pointed out, 2024 is far from 1968.  The country is divided, but not on fire.  Still, as a householder who had the Oakland fire come within three blocks of his house, I'm convinced that making sure fires are well put out is a good practice.

What should Jews do?  Unlike the Jewish fascist government in Israel -- Netanyahu, Ben-Gvir and Smoltrich are basically the Killers of the Jewish Dream -- righteous American Jews should call for debate, call for civilized discourse, positively acknowledge the right to free speech, and at the same time call for enforcement of law, and express their own willingness to let the law be enforced. They should also tell the administrators that if they don't enforce the law properly, they will be forcing Jews once again the protect themselves, and any blood will be on the hands of the administrators. Jews will not be bullied. You do it, or we will. Schmucks.

Budd Shenkin

Sunday, April 14, 2024

Humanistic Medicine -- Definition and Importance


The Definition, Importance, and Extensive Domain of Humanistic Medicine

What is Humanistic Medicine?

If we are to argue for the importance of Humanistic Medicine (HM), and if we are to understand how it needs to be taught, we first have to find a definition. HM is an appealing term with an elusive definition. We can think of it as a term that contrasts with, and partners with, the science of biologic medicine (BM.) The overall goal of medicine is to help people, to keep them healthy in body and spirit, and to ameliorate and repair their afflictions. BM uses knowledge of biology, HM uses knowledge of caring, communication, feeling, and much else to the same ends. Because it is hard to express a compact definition of HM, we will go on at some length here to get a full sense of it.


An Impressionistic Definition of HM

HM can mean interviewing patients to find out where they're at, how best to reach them, how to be empathetic. It can be befriending patients, even while being a professional. It can refer to the adopting the proper stance in the doctor-patient relationship, adjusting according to the problem and the personalities, from (a) active-passivity, to (b) guidance-co-operation, and to (c) mutual participation, as described in a classic article. It can be Taking Care of the Hateful Patient. It can be the long-term relationship that develops between a patient and a doctor with meaning for both of them.

It can mean becoming wise, as old time doctors were reputed to be, rabbi-like. It can be becoming attuned to the cycles of life, from birth to death, knowing when and how to intervene and when to let nature take its course. It can be giving advice that is not strictly medical. It can be being able to call upon literature and philosophy as well as science to help patients. HM is not just a set of principles and boxes to fill out, and generalizations – just as BM needs to be as precisely tailored to individual cases, so HM needs the same precision.

It can mean being part of a team that works with patients when curing is not an option. It can be helping patients navigate so they can do things they really want to do, when it becomes very hard. It can be caring for the bedridden, turning and cleaning, cheering up, relating, simply being there. It can be tending sensitively to the dying.

It can be all of those things and more.


The Extent of HM

Another way to approach the definition of HM is to list extensive examples of what it covers.

Dealing with serious disease

Knowing how to and when to give bad news, such as a diagnosis of serious disease, of returning cancer, of an untreatable condition.

Knowing when to stop treatment and switch to palliative care

Understanding team medicine in end of life care

Knowing how not to shy away from very sick people

Knowing what to do when there is nothing to be done, how to be there with the patient

Knowing the process of caring for patients by families and caregivers

Knowing how to process death, the family's feelings and your own

Understanding the natural course of life and death, and being able to accept it


Patient relations

Understanding emotional distance, how to be close but still be objective

Understanding the various models of the doctor-patient relationship

Understanding the history of relational expectations; the death of paternalism

Understanding the differences of long-term and short-term patient relationships

Experiencing caring for patients longitudinally

Knowing how to handle difficult patients, patients who provoke you

Understanding clinician anger when patients don't fulfill the sick role properly

Knowing how to be emotionally present for patients

Knowing how to communicate effectively and sensitively

Understanding the power relations between doctor and patients

Understanding the power of projection, how patients need to feel they are in good hands

Treating patients with respect, as a patient with disease, not “the thyroid in 208,” not “a fascinoma”

Knowing when to use first names, when to use Mr. or Ms.

Knowing how to integrate professional demeanor with personal and professional authenticity

Understanding both the commonality of patients, but the differences that culture and finances and faiths and understanding can entail.


How the patient appreciates the full experience of medical care

The effect of practice environment

Effect of telephone system, computer system, making appointments, responses to questions – does the patient experience these steps as “caring,” or not?

The effect of the physical environment

The attitudes and practices of staff

The effect of financing on the therapeutic relationship and sense of caring

The effect of making the patient a prime actor in choosing in a medical marketplace

Impact of giving medical care on the doctor

Understanding psychological defenses of clinicians against the pain of their feelings

Understanding the pressure on caregivers in fields where patients frequently die

Enduring and making sense of disquieting experiences and traumatic confrontations that doctors confront – death, disability, pain, suffering, fear, isolation. The anguish of life.

Understanding the impulse to “do something”

Understanding the impact on the doctor of watching patients suffer

Understanding the concept of moral injury, where and how it occurs

Understanding “burnout,” and how it differs from moral injury

Relationships with other doctors and caregivers

Understanding the strengths and limits of mutual support

Understanding how to support patient in face of perceived shortcomings of other caregivers – and how to interact with deficient caregivers

Understanding how to be a team leader, and how and when to play a supportive role

Understanding how to effect good teamwork

Understanding how clinicians can support each other positively and appropriately

Medical ethics and values

Understanding the basic precepts

the patient comes first

do no harm


respect for patients

all patients are of equal importance

no sex with patients

prohibition on taking advantage of the power differential between doctor and patient

Understanding the challenges to upholding ethics

Understanding the concept of moral injury

Understanding concept of Health Fiduciary (similar to financial fiduciary)

Understanding conflicts that arise from serving 2 masters – employer and network on one side, vs. patient on the other

Understanding moral injury that can result in the doctor inhibited from giving best care to patient

Understanding how to effect joint decision making

Understanding the moral imperative of when to refer a patient


Spirituality and religion in medicine  

Understanding, appreciating, respecting, utilizing, and communicating the centrality of meaning, value, and relationship

Narrative medicine

Understanding the basic theory of applying literary concepts to life stories to convey meaning to life, disease, and death, using plot, characters, and metaphors to examine and illuminate 4 of medicine's central narrative situations: physician and patient, physician and self, physician and colleagues, and physicians and society.

Sociology and anthropology perspectives in understanding medical care

The sick role

The role of the healer

Cultural differences; international differences

Changes over time in American medicine

Evolution of the role of paternalism

New understandings on when to stop treatments

Emergence of palliative care, hospice services

New emphasis on team care

In the end, HM can be understood as the emotional, feeling, and caring aspects of illness and delivering medical care, with emphasis on both care-givers and care-receivers. Does a patient feel cared for, attended to, cared for and cared about, can the patient have confidence in skill and arrangements of a whole system? Does a patient feel like a valued human being, does the patient feel known, or does the patient feel like a cog in a wheel, an input or an output, a thing, a statistic? And the same questions can be asked about the doctors and other care-givers. So much of HM is the essence of caring and being thought about and cherished.

In Sum

As we list the extent of the components of HM, it is astonishing how deep and how far HM's reach is. Many are tempted to view HM as an afterthought – do the important clinical biological work, and be nice about it, smile. It should be obvious how mistaken that is. HM is not peripheral, it is central. It is not just a “natural part of the doctor's personality,” it has to be taught and supported. When HMS students were choosing medicine as a career, a majority had in mind, along with gaining knowledge of scientific curative medicine, being a practitioner of the beneficence of medicine, the kindliness of the doctor, bringing balm to the ill. HM is central to the mission of medicine, and along with BM, it needs to be taught and practiced in medical schools as a highest priority.


Budd Shenkin

Saturday, March 16, 2024

Israel, Anti-Semitism, And Our Dilemma


A friend of mine sent me this disturbing, unbalanced expression of discontent by Joel Kotkin from The Claremont Institute. > Imagine, unbalanced right-wing distraught expression of alarm from the Claremont Institute, who'd a thunk it.

Before the war, last February, in an acclaimed blog post, I set out what I thought US policy should be toward the increasingly illiberal leaning Israel. I said basically that much of what had drawn us toward Israel for decades, before the Likud-Netanyahu-extreme religious right descent, had disappeared. So we had to start regarding Israel as an ally of convenience more than an ally of conviction.

Now, of course, our dilemma is even more acute. If Israel makes it difficult to support them, Hamas of course makes support of them totally impossible – except they are getting it. But I'm getting ahead of myself.

In reading the Claremont article, which bemoans what he identifies as rising anti-Semitism and insufficient public opposition to anti-Semitism, I find some agreement. I, too, am appalled at the support given to the lefty teachings.  I am appalled at the pro-Hamas virulence, and the lack of arrests and expulsions when they cross the line.  Lefty faculties are appalling.

But, once again, there is the problem of anti-Israel vs. anti-Semitism.  They are not the same.  I think much of what Israel has done, has been, and continues to be appalling, and it has spawned ever more Israel isolation in world politics.  i find too many Jewish organizations saying, either you're pro-Israel totally, or you're anti-Semitic.  Israel would have a lot more supporters if their politics and West Bank actions and declarations of intent to wipe out all Palestinians were not so dreadful.  Netanyahu and colleagues have squandered the ethical high ground that Jews have occupied previously.  There is a reason so many American Jews, and others who would be friendly, hesitate in their support of Israel.  Most people feel, I think, that Israel has a right and a necessity to exist, but not a right to oppress.  Not to whitewash the dreck of Palestinian and other Arab and Iranian organizations, and not to whitewash the ignorant anti-Semitism of the unwashed left here and abroad.  And certainly not to whitewash all the anti-Semitism exported from Arab countries.  I wish they would all return to where they came from and see how they like living under Assad and other friendly murderers.

Likud and the Israeli right wingnuts have put Jews worldwide in an impossible position. How do you support liberal values and the existence and need for safety for Israel, when the state of Israel's policies are so difficult to support?  It's so difficult to say one hates the government and its policies and that some of its leaders belong in the Hague, but we need to give all our support to Israel and let them do and say whatever they want, when so much of what they want is heinous.  We just have to wait out the crisis, I guess, and hope Netanyahu goes to jail soon, while strongly resisting and calling out anti-Semitism.  Jews need to be judicious -- strong but reasonable, and not exerting wealth and power tools on the universities so prominently, which fuels paranoia and anti-Semitism. Being judicious in these circumstances is really hard.   

One of my friends read the piece and was disturbed. He is dissatisfied, as Kotkin is, with the Democrats – Progressives support for Hamas is really appalling and surprisingly widespread, but he is dissatisfied with the rest of the Democrats as well. He wishes for a moderate third party messiah. I had to say, friend, ain't gonna happen, can't happen, all third parties are destructive -- although I think Kennedy could drain some votes from Trump.  I'm hoping that the security community drops its non-partisan stance and says, we are partisan for democracy and the continuation of American leadership of the free world, and therefore, even though we are predominantly Republican privately, we are dropping our reticence and urging everyone to vote for Biden, or else we as a country are doomed.  Maybe that would help.  The Democratic party, which is not a stronghold of anti-Semitism at all, and which has good policies basically in so many areas, although there are certainly anti- Semites in their Left wing -- is the only hope.  And anyone who thinks that Biden hasn't given enough support to Israel - at great political cost to himself - is mistaken. He is giving more than they have a right to expect.

Anyway. As I used to hear on CBS when it was reputable, That's the way it is.

Budd Shenkin

Monday, February 12, 2024

Gerontology: The Profession vs. The Job


Caring For Older Patients Is Not American Medicine's Priority

There is a prominent paradox in American medicine: we have an ever increasing elderly population, both in numbers of patients and the age of patients, but our capacity to treat these patients is not increasing proportionately. In other words, we are falling short now and if the trend continues, we will be doing worse and worse as time goes on. This is a well known problem, and even if it does not seem to provoke much action, it does provoke words. That's hopeful, in a way, because words are often a prelude to action, although when we look at the problem of global warming, we realize that words are often less effective than the appearance of the crisis in full-blown form. Humans tend to react to crises rather than plan for them, unfortunately.

So that's where we stand, we are talking about this crisis of an increasing population of the elderly.

In August of last year, two articles on older patients appeared in the medical literature, one in JAMA and the other in the NEJM, that illustrate our impasse. What do you do when there is little progress? The JAMA article is one of frustration. The author asserts that the field of geriatrics is so intrinsically interesting and important, yet the number of geriatricians is dropping, and he can't imagine what more can be done to attract young medical professionals. The NEJM article doesn't even mention the crisis of manpower, but it sets out in extensive and thoughtful detail what the authors think ideal arrangements would be to provide medical care for elderly dementia patients.

Here's the JAMA article.

The Paradoxical Decline of Geriatric Medicine as a Profession

Jerry H. Gurwitz, MD

From The Journal of the American Medical Association (JAMA), August 4, 2023 (

The author, an academic geriatrician, bemoans the chasm between the need for geriatricians for an aging population, and the deficient supply of these specialists, that is withering even further.

The situation mystifies him. After all, the work itself is so interesting! Old people can have so many diseases and conditions simultaneously, many of them cannot be cured, the surrounding families trying to help in care can be stretched and exhausted, and putting together interdisciplinary teams for care can be so energizing! Well, Jerry, you say it's “interesting,” I'll give you “challenging.”

Moreover, he says, the money for research in geriatrics is increasing rather than decreasing, even some foundations are pitching in to support the teaching of geriatrics.

Yes, he agrees, the money is not great, and in fact, if you take the time to become a geriatrics specialist after your internal medicine training, paradoxically, you will earn even less than you would if you just stayed an internist! But then, pediatrics pays poorly, too, and pediatrics remains a fairly popular specialty, he says. (He could have looked further and realized that adolescent medicine, which like the geriatrics situation, takes extra time to qualify for, then enables you to make less money than if you had simply started practicing pediatrics, and adolescent medicine also has trouble filling all its spots – he didn't look quite far enough for a correlative situation.)

It must be the culture, he says, where old people are looked on with some disgust, agreeing with Louise Aronson and her great book, Eldercare. And it must be the graduate education councils that don't require medical students and residents to be exposed to geriatrics. (Adolescent medicine wages this same fight, by the way.) And it must be the health care organizations that take the extra money that is paid for treating the elderly (if you code properly, which they do, because it means more money,) but they keep the money for their organizations and their goals and profit, and they don't plow the money back into the organization by hiring geriatricians and serving the elderly better.

Jerry has no answer, no path forward. He is reduced to saying, the problems with an aging population will only mount, and people – you'll be sorry you have been making these anti-geriatrician choices!

Well, he's right about the need, and he's right about societal prejudice (I have it myself – I chose to be a pediatrician, partly because I thought of the dear kids and hopeful families and the futures they had before them, which old people don't.) And tastes vary – some people love working with old people and some don't, and it will ever be so. Like for me – give me the kids, every time.

But the main problem that Gurwitz isn't dealing with is the difference between a profession and a job. There isn't a single reference in his short paper to what it's like to have the job of being a geriatrician. Is it a good job? Are geriatric practices well resourced? Does a geriatrician feel like the captain of a team who can call on A and B and C to deal with the problems of his or her patients? Can the geriatrician identify a problem of insufficient assistance in the home, and assign a member of the team to solve that problem expeditiously, and then to report back, problem solved? Or is it always a struggle, always slogging through sand, begging for this or that agency to come through, looking for financing, etc. Are home supports easily available, with all the durable medical equipment at the ready, all the aides? Are there institutions available that are excellent and welcoming and well-staffed and well supplied and happy, vibrant places, or are they dingy and sad and full of dysfunction and is it hard to find a good one?

How does the geriatrician experience the day to day? Is the office work easy and efficient, or is he or she always struggling to keep up with the documentation required by the electronic medical record that is designed to optimize billing rather than care? Is the geriatrician served by a scribe who does all the work of electronic charting, or does the geriatrician do it him or herself, acting as a data input clerk? Does the parent organization take pride in the geriatrics office, even though it is more an economic drain rather than a profit center?

Does the geriatrician skate through the day or slog through sand to the point of exhaustion?

And the pay, the pay and benefits and vacation time. All the non-procedural specialties need better pay, the current structure of pay is an out-of-control outrage. But the job can make up for lower pay, if it is really well-structured and fulfilling. Is the structure of the job, the agency available for exertion by the geriatrician, the resources at hand – do they lead to great job satisfaction? Do health care groups have a carved out gerontology slots, with attractive job descriptions and resources at hand? These are things that students will see as they make their specialty choices.

Is the substance of the job enough to offset the inferior pay? Is it good enough to make it attractive to make half as much as your colleagues to elect to become strutting orthopedists?

There will always be people who choose to follow their interests and their ideals into a chosen field, no matter the consequences for their job. They can accept the indignities because they are obeying a higher calling, and they are following their passion, their bliss. That's true of all walks of life. But it makes it a lot easier to do so, and many more will choose them, if the jobs are really well-structured, well-operated, and well-conceived.

So my advice is, Jerry, is go work on that. You can do it right there where you are. Construct an ideal operation. Show the world what you can do to make the life of a geriatrician a dream. You don't have to match the orthopedist's pay and lifestyle (but you should get close, say 80% close), but you do have to make the organizations you are working for pass your increased remuneration down to you and not just spread it around the group. Make that extra degree worth something. And make the job one where you skate through the day, not one where you are continually slogging, which takes resources and organization. Match the job to the attractiveness of the profession, and maybe then you will get to serve society with what it needs, more services for the aged provided by the proper provider with the proper organization.

What Gurwitz has missed, in sum, is the difference between a profession and a job. While the profession of geriatrician can be terrific, the job of being one often sucks.

Here's the NEJM article:

    Toward Gerineuropalliative Care For Patients With Dementia

    Krista L. Harrison, Ph.D., Nicole Boyd, M.D., and Christine S. Ritchie, M.D., M.S.P.H.

    from the New England Journal of Medicine (NEJM), August 30, 2023

And lo! Just a little later in the same month comes an article in NEJM, a more hopeful one, on a similar subject, caring for older patients with dementia. Where the JAMA article sees an intractable problem in caring for older people because specialists are not being produced, this article posits a model of care that, they say, could be adapted for generalists rather than geriatricians, perhaps because the geriatricians are just not available. (Again, the same dilemma arises in adolescent medicine, where specially trained personnel would render excellent service, but where numbers dictate that they be mostly researchers, teachers of pediatricians and a referral specialty.) This service model also highlights the need for non-fee-for-service payments – nothing new there – and in a hopeful sign, Medicare has started a model program where capitated care would be available. Beyond those small nods to practicality, however, the article is a rather typical academic approach to matching resources to need in an ideal world. The summary chart in their article is impressive. What a plan! I only it could be implemented!

I would think that this interesting chart would be helpful in actually shaping programs in the field, but that remains to be seen. The problem is, who would try it, and why? Yes, the ideal of helping people is always there. If a program were to be mounted in academia, the careers of the progenitors would be enhanced, and staff working on the project would find their jobs enriched. But when a field with obvious needs has shown so little progress over time, there's a reason. Here and there in the country, there would be enthusiasts to take up the model.

There are deeper questions that need to be approached to really understand this situation. Let's just mention them.

Is the country prejudiced against old people? Yes, our culture does not honor the old very much. Put them out on the ice, some urge, the gerontocracy takes up slots that should go to younger people (like the author of that screed, one surmises.) Or probably, the wealthy can often take care of their oldster problems privately, so programs that would serve everyone are not their concern.

Why does the profession of medicine allow this situation to persist, and not target their efforts toward the country's problems with primary care and chronic care? Well, the profession of medicine is not a whole, it is pieces, and the haves are the procedural specialists, and the have-nots are the chronic caregivers, the primary caregivers, the procedure-less specialties. And as always, the well off have more resources than the less well off, and they use those resources to reinforce their position of privilege.

Why do people wait until situations get out of hand to react, why don't they see the future and plan for it? Well, they're not as smart and as disciplined as you would wish. You can plan and act thoughtfully in small groups, but not the larger ones, where entrenched interests are self-protective, and not naturally inclined to sacrifice their short term interests for putative long term possibilities. Present perks are hard to fight.

But, whatever. In the field of geriatrics, if you want to do good, it's a good idea to focus on the job rather than the career. Make it a rewarding job, and they will come. An interesting profession, OK, yes, but that's speculation. The job that you can see and feel, that's what will attract new entries.


Budd Shenkin

Wednesday, January 31, 2024

Budd's Blood Pressure - Fascinating!

Here's a story about my blood pressure.

I know, “Fascinating! Let's hear it, Budd!” Then I'll tell you about my aching left foot – what a problem that's been!

Actually, I've wanted to tell this story since it happened to me last week, and I planned to adumbrate it with observations of the medical care system. Here's the very short version:

For some reason, I really don't remember why, after more than a year of not checking my BP, I checked it while I was in Maui, and found it elevated, to 142/84. Not a deadly level, but concerning, because one, it was rising, and two, when you get past 140 systolic, the danger of events starts to increase. And me, well, I always over-react. Can't help it.

So when I got back in town the next week I tried to get in touch with my PCP, my friend and long-time colleague Jim Eichel, who used to work for me and now works for Stanford. Stanford. A hospital, and thus, a bureaucracy. I messaged him and got back a message from a physicians assistant who said my BP wasn't so bad, and what about life-style? Give me a break. I'm a doctor with 31 years of education and over 30 years of practice, and I'm going to be talking to a PA whom I don't know? Next they'll be telling me to check in with an urgent care center, where I would get an unsupervised PA.

So I called and asked for an appointment. Sure, I could do a Zoom call in 3 weeks (you can't measure a BP in person on a Zoom call, Stanford) or I could see Jim in a couple of months. My blood pressure is rising (and this phone call didn't help, obviously) and they're telling me that my PCP isn't available. Yet they'll claim high quality care. NOT, people! Access is part of quality care, and personal contact with your own doctor is a part of quality care. Baiting and switching is not part of quality care, Stanford.

So I figured I'd email Jim privately, which I did, and in a couple of days he got back to me and wondered if we should start hydralazine, a 4th drug for my BP. He thought maybe yes. I wondered.

But in the meantime I figured, before Jim got back to me, let me call my cardiologist. I hadn't seen him for years, when I had a rhythm abnormality, but what the hell. I believe in specialist care, and if the US doesn't have enough primaries and a surfeit of specialists, I'll go with that flow. Turns out it took me maybe 2-3 days to see my cardiologist – it would have been sooner if I had been an “active patient.” Since I was just an old patient, they required a referral. Well, Stanford would be no help there so I got my doctor step-daughter to send in the referral – we regularly help each other in getting ourselves through the system. So, the fact of the matter is that I got to see my cardiologist before, way before, I could see my PCP. And actually, not only that, but then I got an echo-cardiogram and a renal ultrasound the very next business day. Eventually on the weekend I talked it over with Jim and we were all cool – I got to tell him what my cardiologist said about him, that he's the best PCP in the area. I love delivering good news. Jim is such a dear man, really, such a sincere and dedicated and knowledgable doctor who doesn't even tell me I'm over-reactor, although he doesn't contradict me when I confess that I know that I am. Jim's personal humanitarian instincts and practice are disserved by his Stanford system, seems to me.

But that's not really what I wanted to say in this post, enlightening as it is. When I visited Eric, my cardiologist, we talked more about the case, and he said he doesn't really like to add drugs if he can help it. Well, I want to stay in a good range, not a dangerous range, but I didn't object. So Eric said, it doesn't look like you need to lose weight. I could lose 10 pounds, I said. OK, do it, he said. But then, as we talked about the case, I realized that yes, I didn't add salt to my food, but I really didn't avoid it, either. And I eat a lot of prepared foods, which I knew were salty. I was just relying on my meds to counteract it. So I figured it's time for me to really make an effort.

And that's when I made my discovery. I started reading labels. Every goddamn thing has so much salt in it! My friend Mary Lou, whose son does catering, said that he adds salt to everything because it makes things more tasty. And that's what all the food companies are doing, the same thing. They are honoring sales and taste and shortchanging health. Salt just isn't good for you.

But, maybe that's an overreaction – I don't know, I overreact. So I figured, fresh fruits and vegetables, you can't go wrong with that. I'll just go that route. I try to eat a lot of them anyway, I'll just step it up. Which I did over the next few days. And, amazingly, here's what happened. Look at the BP change!  I went low-salt on the 25th, I think.



8:15 AM




2:04 PM




10:10 AM




7:20 AM




8:40 AM




9:15 AM




9:30 AM




8:45 AM




8:30 AM




5:25 PM




5:00 PM




5:30 PM




9:00 AM



7:55 AM




7:25 PM




5:35 PM




And not only that – when I went to work out, I got my maximum heart rate to up 151, which is exactly what my max ought to be for my age. I figure I was under toxic salt syndrome (which I just named.) How amazing is that?!

So then I went to Berkeley Bowl, our local supermarket that caters to discriminating customers, and I was able to find many low-salt items – canned tomatoes with zero salt, canned beans with almost no salt, lots of things. Plus their usual amazing selection of fresh produce.

So there it is, that's the post. I'll have to change my diet, but who knows what other good doing that will do? You just can't go wrong with fresh fruits and vegetables. Now, to figure out how to make soups with no salt – Insta-Pot, gifted to me by Sara a year ago, here I come!

Sitting down and talking with your doctor really has no good substitute, in my opinion. But then, I'm an over-reactor. But over-reactors need care, too.

Budd Shenkin

Sunday, January 14, 2024

Democrat, Republican or Independent? Friendly Debate


I have some friends who are frustrated with party politics. Here is what they and I write to each other:

Friend One

It’s remarkable that 43% of Americans identify as independent, while only 27% identify with R’s and another 27% for D’s – a new low for D’s.  As a card-carrying independent, I applaud the steady growth of rejection of both these miserable parties whose time has long gone. The Republicans have lost all semblance of conservative principle and are held hostage by neanderthal nihilists on the right; the Dems are awash in identity politics and woke insanity, and still absurdly believe – despite all evidence to the contrary – that government can offer effective solutions to all our social ills. Both parties are craven and amoral, self-absorbed liars who wallow in a broken system.

And yet, when nearly half of America is ready to reject them and vote independent, who do we get to vote for? RFK Jr.


Friend Two

Thank you for the realistic view of our parties today. And it ain’t no party!

I am still a registered Democrat although I have identified as an independent for >20 years. I share your views. I too am waiting for an independent candidate that I can support.

But I feel differently, so here is what I wrote back to them:


I don't feel the same way.  I'm a Democrat and always have been.

It's useless to talk about the Republican Party.  I never liked them, even when they were a decent party.  They have always been the rich man's party, the country club party, the penny-pinching party, and in the past the anti-Semitic party, and they may be still, those of the old party that are left.  I like the old Mort Sahl line, What's a liberal Republican?  They're for change, just not now.  And now, those old me-first Republican stick in the muds, the help yourself don't look to me to help Republicans, are far too liberal for the party that has essentially been body-snatched.  It's like when SBC bought ATT and took the name, because SBC had a bad reputation.

The Democratic Party has a much better heritage, especially since FDR.  FDR - tripling down on his cousin TR - thought that government should help people, not call balls and strikes.  His Four Freedoms rang true.  One or two of you might remember my paeon to the Four Freedoms --  In the great questions of the day,the Democratic party has generally been on the right side.  They get a bad rap on defense -- they are not willing to kowtow to the generals, but they have always been strong.  I could go on about the virtues of their heritage.

Has the extreme Left bodysnatiched the Dems?  No.  It's a varied party, as you have to be in a two party system, and putting together alliances is always tough.  I admire AOC, but not so much her chosen lefties, some of which are horrible.  The Black caucus is a problem, whose anti-Semitism is beyond criticism.  I find some of them really irritating, and the identity politics that Rick cites is awful, just awful.  But the bulk of the party has the right attitude and the right tilt.

Have government programs failed?  Not really.  The best ones are those that write checks -- social security, Medicare, Medicaid.  Where would we be without them?  What about nutrition programs for the poor?  So many others.  Government can't offer solutions for all social ills, of course that's true.  I don't know who believes that it can.  But it already does so much, and could do so much more if given a chance.  If you look at the social welfare democracies of Europe, especially Scandinavia, you can see how a government can lift up a whole country over time.  Sweden was known as Poor Sweden, until the Social Democrats took over about 100 years ago.  Now they are world leaders in a country not blessed with many natural resources.

Is bureaucracy a failure?  Often, in this country.  Can it be stupid and stultifying and frustrating?  In spades.  The trick is to devise programs and policies that avoid large bureaucracies, or that decentralize enough so that there can be competition within government.   I think, for instance, that Medicare should split up into smaller units to administer the program, and compete against each other.  That's a question of design, and there are many others.

In a two-party system, in many ways it makes more sense to choose the party instead of the individual candidate.  We all love the great legislators, but when push comes to shove, would you rather have a pretty good Republican or an average Democrat?  It's the vote that counts.  There will always be leaders and followers in organizations, and the House and the Senate are organizations.  Overall, much as I detest her personally (can't say why, exactly) and vote against her in every election, it's better to have Barbara Lee in the House than any Republican that runs against her, no matter how great, because it's their votes that count.  Want a great Republican thinker (there must be some) who votes with Marjory Taylor Green on every vote?  What good is that?  Unless the Republican you elect is leading a group to a new Republican party and is willing to vote independently, a vote for any Republican is a vote for the body-snatched party, a vote for Trump and his acolytes. 

Parties serve a function in our democracy.  I find much to criticize in the Democratic party, and not just on the radical left (which, given the conservative structure and function of politics in this country, would be center or center left abroad).  I decry their gerontocracy, their suppression of competitive primary elections, etc.  But without them, we would live in chaos.  If there were more parties than two, we would soon be subject to the same woes of other countries like Israel, where a small swing faction gets to have its way.

And that's the way it is.


Friend One

As always, it’s a delight to read your thoughts, Budd. Much of what you say is persuasive, and all of it is so forcefully and mellifluously presented!

Just a few points in reply, please.

First, it’s telling to me that, when you talk about the Democratic party, you’re somewhat forced to look way into history, rightfully extolling the pedigree that FDR (and TR before him) laid down. I share your deep admiration for both of them, but that’s almost a century ago. It has limited relevance, in my view, to those who populate the party today. Yes, the Dems have long been the party of compassion, but I see woke culture – which permeates not only politics, but almost every aspect of modern life – to be the antithesis of respect, tolerance, inclusion and the celebration of diversity (in all its aspects). Today’s Democratic Party is awash in identity politics, and you acknowledge all the baggage that comes with it: racism/anti-racism, antisemitism, character assassination, mob rule, the dumbing down of academic standards, the polarization of our society.  I know you see all that’s wrong with this party today – you say so – so I won’t go on and on.

Ironically, the best argument for the Democratic Party right now, in my view, is the job Joe Biden has done as President. He gets little credit for it, and the overwhelming view – of all Americans – is that he should not run again. But his presidency has been remarkably strong, in both domestic and foreign policy.

The real question is, where are the visionary, talented Democrats who are leading the party to a better future, post-Biden? I submit that they are nowhere: not my pal Cory Booker, who has about as much support within the party as my dog, Ollie; not Gretchen Whitmer, who ought to be their candidate for President, but no one in the party had the balls to try to make that happen. Not Pete Buttigieg, who has disappeared altogether within the Biden Administration. And certainly not Kamala Harris, the heir apparent who is rightfully loathed and disrespected by everyone in the United States, in both parties.

So I don’t hold the brief for the Democrats that you do. (Being an independent in Maryland is pretty comfortable: we have plenty of good Republicans to vote for on occasion, like former Senator Mac Mathias, former Governor Larry Hogan, former Congresswoman Connie Morella, along with many great Democrats like current Governor Wes Moore, both our US Senators and Rep. Jamie Raskin.)  

In general, we agree completely about the Republican Party. No discussion needed there.


Thanks, as always, for the compliment!!  Warms my heart and my figurative pen.

The greatest sin of the Democratic party is not to provide for the future.  The best companies identify, recruit, nurture, and promote talent, and meld all the talent into teams that produce and provide for the future.  The Democratic party hardly does this at all.  There's lots of work we don't see -- candidate recruitment, for instance.  But the talent that's there gets crushed under committee chairs who stay forever -- in contrast to the Republicans, by the way, who term out chairs.  And they don't sunset.  And they don't have ways to bring governors into national spotlight, as they could by having commissions to approach problems, for instance, composed of governors, cabinet officials, leading legislators.  It's a severe organizational problem.

Our era has been conservative, ever since 1980.  Even the Clinton presidency championed neoliberalism, conferring further impetus to inequality.  The lack of caring for the middle, working, and lower classes has been a hallmark of these YOYO years, even with Clinton.  Instead of real programs and tax policies to help those classes, we have devolved into minority care, with Hillary nearly running out of breath as she listed the minority groups her administration would help.  It's a mark of progress that Biden talks more about helping ordinary people in general.  One idea he took up, but which the Republicans have let lapse, was Rosa DeLauro's child tax allowance, which lifted about half the children in poverty out of it.  He also has been trying to revivify anti-trust, as Bork and the Chicago School and the Republicans have allowed concentration of business entities to run rampant, even giving them the rights of citizens in elections, as we know.

So, given that conservative environment, we can't point to big wins as in the previous era.  In fact, just look at tax policy, and we can point to big losses.  But I have confidence, perhaps misplaced, that eras change, and given enough time in power, the Democrats would regain their senses and concentrate on lifting all boats.  After all, it's their legacy, and enough believe in it that I think it would reassert itself, given the right environment.  And as in the late 1930's, a major obstacle would be a recalcitrant SCOTUS, that will have to be neutered somehow, someway.

And I would be remiss if I didn't mention that it is even possible, given some longevity of Democratic governance, that Modern Monetary Theory will be given a good test!  And that we will find governmental policies to help us transition to a new society where increased productivity is translated into increased leisure and security for all.  And where climate becomes a #1 priority.

Dreams are the salvation of life.



Talking with friends is one of the great pleasures of life.


Budd Shenkin