Comparing what's happening now to Watergate

My book club has men of a certain age, and several are lawyers.  As it happens, two of them worked on the Nixon Watergate inquiry, one on the House side and one on the Senate side.  They reflected on the current Republican objection to the investigatory process -- you know, the  Matt Gaetz led foray into the secure room, first invasion and then 17 pizzas.  Here's what Jeff and Bruce had to say:

Impeachment Inquiries

Jeffrey

The Nixon impeachment inquiry staff conducted private interviews with key witnesses.  Some came voluntarily, like John Dean.  Some were under subpoena, like G. Gordon Liddy.  In my early days on staff, I would sometimes escort these fellows from the downstairs security checkpoint upstairs.  Liddy refused to tell us anything more than his name, his military ID no., and his citizenship (United States).  He refused to sign his name in the logbook. 

These interviews were not conducted by members, and they were private.  I believe staff from both parties were present.  I don’t recall public hearings until the Judiciary Committee members began debating articles of impeachment. 

Bruce, What’s your recollection of how the Senate treated its witnesses in the Watergate investigation?  Public hearings we recall; but were their interviews first, so Senators knew what to ask?

Interesting that we have a Book Club with both chambers represented.

Jeff

Bruce

Interviews first.

As I recall, most of the interviews, either under subpoena or not, were conducted by staff who were hired either by Sam Dash, Chief Majority Counsel or Fred Thompson, Chief Minority Counsel. All interviews were attended by staff representing both the Democrats and Republicans who then reported back to the Counsel who relayed the contents to the respective senators and their staff on both sides of the aisle.

I did sit in on interviews of members of the Domestic Council within the White House (John Ehrlichman) as a member of the Majority Staff of the Committee.

Jeffrey

Right – staff representing both parties would sit in on interviews and then report to the members.  The Trump impeachment inquiry has House members from both parties conducting the interviews, no doubt with staff whispering in their ears.  So in terms of transparency, this is a fortiori what we did with Nixon.  If this is correct, why the Flash Mob of Republicans yesterday?  What’s their complaint?


Budd Shenkin

A Small Poem

When a man of 77 dreams of an undiscovered future,

It could be presumption,

but it is really habit,

now made sudden by time.

A Practical Quality Agenda in a Primary Care Practice

If you ran a primary care practice, how would you approach the issue of quality of care?  I faced this issue in my practice, and I thought about it in depth.  Twelve years ago I wrote this paper on how I thought about it.  It's very practical.  Much of what you read here you will not have read elsewhere.  I commend it to your attention.

One note - although much of it holds up despite the time lapse between when I wrote it and now, EHR's were not widespread then; now, they are ubiquitous.  So that part of the paper is partially outdated.  But other than that, as I read it over, I think much of it still holds true. 

If you want to improve your practice quality, you will need a roadmap.  I think this paper might help.

Editorial note: I have 48 footnotes for this paper, but somehow it's hard to put them into this blog, but trust me, what I say is well founded!

 

QUALITY IMPROVEMENT IN PRIMARY CARE PRACTICE:
CHARTING A PRACTICAL COURSE

We have known for some time that our medical care system is failing to implement what we know and what is theoretically possible.  The Institute of Medicine found that the medical enterprise has outgrown the capacities of our basic institutions, the great variability of care implies quality deficiencies, indicated preventive measures are inconsistently applied, diffusion of knowledge is chillingly slow, and indicated care is offered a random adult patient at an estimated rate of 55%.  Most recently, the UCLA-Rand group has extended their findings to indict ambulatory pediatric care as well.  They conclude: “Strategies to reduce these apparent deficits are needed.”

Indeed they are.  Our primary care group (mostly pediatrics) has been addressing ourselves to quality improvement (QI – used here to denote general quality efforts rather than any specific method) for five years in an organized way, and in doing so have discovered approaches that might help others to find paths for QI for their practices.

Our first discovery was that there is indeed no current roadmap; we could find no articles in the literature examining QI in offices in detail.  If only we had the know-how to diagnose and treat practice as we do a patient: take a history, do a physical examination, take measurements, and proceed with well established plans for prevention and treatment!  But quality science has not yet provided office practices with the equivalent of even vital signs, let alone a diagnostic outline, a Practice Quality Index, or established modes of action.  Consequently, if you are designated the Quality Officer in a group practice, at the moment of your appointment, you face near-virgin territory, and will need to invent and discover your own path forward.

Practice roadmaps will differ, of course, since practices differ widely in their abilities, needs, proclivities, visions, patient populations, and organizational structures.  Nonetheless, every practice seeking an organized approach to QI will most likely need to ask similar questions.  For the question, “What area does quality encompass?” we have found three separate sectors.  For the question, “What modalities of action do we have?” we have found two distinct modes.  For the question, “What are the constraints on our activities?” we have found three impedimental areas.  And for the question, “What practical projects suggest themselves?” we have found so many that there will clearly be no end to this quality journey.


OBJECTIVES, MEANS OF INTERVENTION, AND CONSTRAINTS

Pay For Performance (P4P)

Pay For Performance (P4P) is the most conspicuous current embodiment of QI.  P4P identifies elements of quality that are important and which are putatively easily measurable through claims data, thus finessing the difficulty of actually measuring quality on a non-research basis.  P4P then rewards either health plans or individual practices that score well on the measures chosen.  A practice will be tempted simply to take the P4P measures, aim at them, and call that their program.

To do so, however, might be a mistake.  The elements of practice are generally important, true, and the financial rewards are of course attractive.  But P4P has marked weaknesses.  P4P measurement validity is itself questionable.  Scoring well on P4P items does not indicate general practice quality, especially if the practice “teaches to the test” of P4P indicators, and concentrating on P4P may well “crowd out” more important QI efforts.    “P4P programs are being implemented in a near-scientific vacuum.  There is scant evidence about the appropriate focus, effectiveness, and the general circumstances in which they may work best.” Thus, although P4P might well turn out to be an element of a practice’s QI program, it will be too thin a reed upon which to build an entire QI program.

Three Realms of Quality

A wider view of practice quality can be obtained from looking closely at the definitions of quality.  Most obvious to us is biomedical quality, defined by the Institute of Medicine: The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.   A second area, the way in which care is provided, is also defined by the IOM: timeliness, patient-centeredness, safety, effectiveness, efficiency, and equitableness.  These qualities would apply both to how clinicians function (tending to labs and X-rays promptly, involving patients in decisions, etc.) and how the office as a whole functions (waiting times, respect from staff, ease of navigating the system, etc.).

The third definition of quality would be even wider: How well a practice helps its patients.  Unlike definitions one and two, this wider definition includes the humane services of counseling, befriending, understanding, and supporting patient, not only directly in the office, but by referral to allied resources. 

As scientific clinicians we would adopt objectives from the first definition and the clinical aspects of the second; as directors of a practice we need to consider the second part of the second definition, the office experience for patients; and as humanitarian clinicians we want to consider the third definition.  Clearly, then, when faced with the possibility of choosing objectives for QI, a practice can choose from a very wide field.

Two Modes of Intervention

Each QI objective chosen will need a matching means of intervention.  The plethora of approaches to QI  can be divided into two types.  Professional Enhancement (PE) aims to improve the mind, skill, and motivation of the clinician.  Systematic Reengineering (SR) aims to improve the operating mechanism of the practice within which the clinician performs.

Clinicians almost reflexively tend to think of QI in terms of PE.  They want to improve their knowledge, memory, understanding, and motivation.   They think of following the literature, continuing medical education, certification and recertification, clinical performance assessment, being reflective, listening to and caring for each patient, searching for the hidden meaning behind patient visits, and detecting disease early from small clues.  Clinicians tend to remember instances when they stopped short in leaving the exam room when a small remark of a patient hit home, how they returned to the patient for more history and examination, and how two weeks later an operation saved a life.  They remember when a bit of knowledge popped up in their minds and led to a smart and important diagnosis.  They recall the meaning they bring to some patients lives, and vice-versa.  This is traditional, palpable quality.

Health services researchers and administrators, by contrast, tend to think in terms of SR.  SR comes from the industrial quality experience, where establishing regular procedures aims at decreasing variability, with the mantra “do-it-once-do-it-right.”  The SR approach finds recurrent stereotypic situations within medicine’s endless complexity that can be choreographed for standard execution with low variation, and hence higher quality.  SR thinks of care plans, flow sheets, and forms.  The goal is to imbed the clinical team in a system that makes it easy, rather than a constant challenge, to do the right thing at the right time.  For system engineers, the clinician is sometimes thought of as a standard commodity. Instead of individuals, SR thinks of teams: “Ranking (of personnel) is a farce.  Apparent performance is mostly attributable to the system that the individual works in, not to the individual himself.”

A practice can and should use both approaches.  True, the effect of PE is more assumed than documented, in contrast to the well-measured impact of SR.   True, that the obstacles to effective education are remarkable.    Nonetheless, some of the assumed superiority of SR must emanate from the more easily measurable nature of SR applications.  Stereotypic situations are inherently more easily measured than the qualities PE aims at -- human relations, complex diagnoses, unique situations, and judgments as members of adaptive organizations.  Sometimes SR will be appropriate -- narcotics control is better handled by a computerized check-in, check-out system than by education on the harms of addiction.  But other objectives require PE --- education, training, and reinforcement are more appropriate to improve empathy than signs on the wall saying “We Care.”  Both matter: the quality of the clinician, and the system in which he or she operates.

Three Constraints, and Possible Solutions

If there were not severe constraints on the abilities of practices to pursue a QI program, programs would be popping up everywhere, yet even in academic faculty practices are “in an infancy stage” of QI.  The constraints on QI actions can be summed up as organization, cost and effort, and measurement.

Organization

Realistically, for a QI effort above minimal scale, it will be easier to envision an organized QI effort than to actually accomplish it, because highly organized group practices are a rarity.  Most small groups (groups of six or fewer physicians deliver about 2/3 of the primary care in the United States) are partnerships with individualistic physician-partners, which are inherently hard to lead.  While many physicians are natural leaders, few are trained in management and quality science.  Moreover, the QI effort will require time and energy to analyze needs, to meet and communicate, to strategize, to revise practice protocols, to produce practice aids, to track progress, etc.  The time taken will need to be stolen either from clinical time (which, unlike QI work, is directly remunerative), or from scarce time off.  Yet most practices will not want to pay a clinical leader for this time and effort because of the traditional debilitating conceit of practitioners that only patient care should be compensated, and that administration is “pushing paper.” Some clinicians, fired by idealism, will enroll themselves as a “champion” of a QI project once, or perhaps twice.  But beyond that, without payment, the champion’s QI leadership will recede.

By the same token, QI innovation in office operations requires a sophisticated practice manager, one able to envision programs, collect and analyze data, and manage personnel with changing roles.  But such managers are scarce, and hospitals, specialists, and multispecialty practices compete strongly for their services.

To be well enough organized to pursue a serious QI program, the practice will need to make a leap of faith, and break away from prejudice.  It will need to support talent that is already in place, or recruit new organizational talent.  It will need to believe in the ultimate advantage of investing in organization.  The increased cost of an improved organization may not be directly recompensed by QI efforts themselves.  But as a side benefit, a highly organized and well-run practice may bring other advantages to the practice.  Better-run practices can become more productive and thus make more money.  Better-run practices can use mid-levels or contract physicians, and may expand to additional offices and extended hours.  They might expand into other allied clinical fields, such as travel medicine, or lactation classes.  They can negotiate with insurance companies in a more organized and successful fashion.  They may attract more talented graduating physicians.  Morale in well-organized practices can be superior.  They can become, in fact, the cream of the crop and face the future with increased confidence.  In other words, the solution to the organizational obstacle may be to face the music and invest in oneself.

Finances

Organizations run two kinds of costs.  Routine QI costs are those of maintaining competence, such as fulfilling a required 25 hours of CME per year, or reviewing employee performance in patient relations.  Investment QI costs involve more substantial efforts to upgrade and improve.  For example, the American Academy of Pediatrics has apparently endorsed 162 separate points of advice that a pediatrician should impart to a family over the course of pediatric care.  If a practice endeavored actually to follow the Academy’s directives, this Herculean effort would clearly be a significant effort to upgrade and improve its service.  The costs would occur both at the initiation of the project – change – and the ongoing effort – maintenance. 

From a business point of view, one would expect routine maintenance to be included in general overhead as “the cost of doing business.”  Investment costs, however, would need to be covered by enhanced revenues.  It could be that psychic “idealistic revenue” could cover the cost off one or two practice innovations, but over time idealistic energy would usually wane, and financial enhanced revenue would be necessary.  This would be equally true for for-profit and not-for-profit enterprises.

What makes QI investment particularly hazardous is the well-known difference between innovation in medical care and other fields.  In a classical free market, consumers recognize higher quality and may pay more for it, and/or higher quality at the same price accrues more business and increased profit.  Higher quality clinical care, however, is often invisible to patients, payors, and even colleagues.  Raising prices often accrues little increased revenue since prices are set by insurance companies.  If additional patients are attracted, many practices see little or no benefit, since they are often already very busy, and adding additional clinicians can yield little profit under the partnership model, since new clinicians quickly become partners and share in the proceeds, leaving little if any additional profit for the innovators.  Thus, investing in QI is often likely to reward patients with improved care and clinicians with psychic well-being, but to penalize practices with unrecoupable investment costs.

Solutions to the financial problem are at least threefold: (1) adopt changes that are low-cost; (2) discover changes that are billable and thus support themselves; and (3) find innovations that produce a joint product – for instance, a change that simultaneously improves quality and efficiency, thus enabling a practice to make more money indirectly.   Examples for solution (1) would be many PE interventions, such as journal clubs and in-house educational meetings.  Examples for solution (2) would be achievement of P4P objectives, use of screening tools which can be charged for, and making additional patient appointments to monitor chronic disease (this latter profitable only if the practice is not working at highest capacity already).  Another example would be convincing an insurer to pay higher rates in light of improved quality.  Examples for solution (3) would be using encounter templates and questionnaires that would improve visit efficiency at the same time as improving quality. 

Measurement

Clinical quality measurement has a long history in research, but few examples applicable to a practice on a routine basis.  As scientifically trained clinicians, we know the importance of measurement to ensure validity of accomplishment; as practice managers, we know its importance for motivation of personnel.  If the practice should adopt laborious data collection, however, this allocation of resources could restrict QI efforts to only one or two objectives for years, and become so burdensome as to sink the whole QI enterprise.

If the practice could be nimble and inventive, however, measurement would not bog down progress.  The goal, after all, is improvement in a single practice, not scientific proof of replicability to other practices, nor achievement of statistical confidence levels.  Some QI steps can prove their worth on a prima facie basis simply by their existence – for example, instituting a regular channel of communication with a social service department, thus improving referrals.  Other improvements may be obvious – for instance, the dwindling height of the pile of pending laboratory reports, or the newly-empty waiting room as check-in procedures are improved.  Some will have intermediate measurability – for example, using P4P biomedical objectives as generated by either practice or insurer, but in the latter case rechecked by the practice.  Another example would be measuring total visit times (time from patient check-in to check-out) using appointment software along with other in-office adaptations. Subjective measures may have validity – for instance, increasing spontaneous compliments from patients, improved scores on patient satisfaction surveys, and the feelings of clinicians about their work.  Some objectives will be stubbornly immeasurable – for instance, the performance of clinicians with non-stereotypic complex diagnoses.  Importantly, the practice needs to resist the impulse to improve only the measurable: “Everything that counts can’t be counted, and not everything that can be counted counts.”


A PRAGMATIC APPROACH

In this welter of considerations and absence of a standard approach, how can a practice proceed?  The important first step will be for the practice formally to accept the QI challenge, and to appoint a QI leader who is apportioned time and payment to do the job.  The leader then needs to start planning, involving practice members widely to ensure that the results aimed at are highly valued. The planning process will be constant and reiterative, as values, objectives, interventions, organizational feasibility, and financial reward are constantly balanced and rebalanced. The hope would be that not only the agenda, but also the process itself would initiate or strengthen a Culture of Quality in the practice, where quality is not in the back of the mind, but a constant preoccupation.  This culture will in itself breed success, perhaps in unforeseen ways.

The resulting QI agenda, whether narrow or wide, will need to generate objectives from quality definitions one, two, and three; choose SR and/or PE approaches for each objective; and find ways to overcome obstacles one, two, and three. Table One gives some idea of the variety of objectives a practice could consider, and the criteria by which they could be judged.

Practices are so different that it is clear that agendas will need to be very individualized. Emphasizing PE or SR would depend on a practice’s self-assessment – for instance, are strong clinicians hampered by disorganized processes, or are clinicians in need of stimulation, or both?  Likewise, is organizational capacity so low that only PE strategies are possible?  For all practices, it would make sense to include initially some “low-hanging fruit,” since initial successes are important, as well beginning on longer-term objectives.  P4P objectives would often be the “low-hanging fruit.”


A Concrete Example

To help in visualizing possible practice agendas, here is an example of a two-year initial agenda with some explanatory detail. 

Several P4P objectives successively, according to offers of reimbursement by payors, probably starting with immunizations.  Each objective would have to be accepted according to the extent of necessary effort – in other words, will it be worth the work.  PE would include educating clinicians on “immunization opportunity visits.”  SR would be clear charting on a separate chart page, medical assistant reviews, and patient recall from billing data. The financial obstacle would be mitigated by health plan payments, and perhaps additional visits from the recall program. Conceptualizing and organizing the effort would be the biggest obstacle, but once done, the same organizational pattern could be used on further P4P projects. Measurement would be by the health plans – as checked by chart review by the practice, as necessary.  These objectives could be “low-hanging fruit.”
Production and implementation of templates.  These practice aides (SR interventions) promise to reduce variability and, as a joint product, to improve efficiency. They change acquiring and imparting standard information from oral-aural to the more efficient and effective utilization of questionnaires and handouts. Pediatric examples would be a questionnaire for a first visit for wheezing, well visit encounter forms for various age groups, and handouts for anticipatory guidance.  Adult examples would be use of routine questionnaires for alcohol use, tobacco use, and depression; and introduction of diabetic flow sheets.  

They would require some organizational leadership and cooperation to produce among the clinicians, and while they would take time and effort of no small degree, there would be little out of pocket costs.  If well designed and accepted by clinicians, implementation would not be difficult, since it would consist merely of inserting printed forms into the visit.  The net financial result might be positive, since templates such as these make a clinician’s work easier and more efficient.  Measurement requirements to assess the innovation would be minimal, since there would be prima facie decrease in variation.  But unquestionably these projects would require significant thinking, cooperation, time, and effort.  Predicting ultimate profitability would not be certain.

Total visit time (TVT) reduction and improved telephone performance.  These efforts would aim at the second quality definition, service.  Since this would involve primarily non-clinical staff, they could run parallel to clinical efforts without overstretching the practice.  Interventions would start with measurement of TVT, and telephone surveys of service conducted by fake patients.  SR interventions would be procedure outlines for staff, supplemented by training (PE).   These would require extensive leadership and design, and possible information technology consultation.  Improved service will be obvious to patients, and thus more patient volume might result.

Periodic case conferences.  In-house conferences where clinicians trade their puzzles, triumphs, and even failures, promote learning and quality consciousness.  Another version calls for mutual chart review, where the clinicians read each others selected charts, and discuss not only the cases but also the documentation and workups.  Conferences on “difficult patients” with experienced guests or group members can improve empathy (definition three).  A PE effort, it requires little organizational effort, entails little financial input and no risk.  No objective measurement is possible.

Encouragement of participation of one practice member on hospital QI committee.  Another clinical, PE action, this would educate and perhaps inspire one clinician at little cost, although one must recognize that 12-24 hours or more spent per year is not insignificant.

Establishment of personal liaison to one social service worker.  This would be an easily accomplishable step requiring initial telephone inquiries and perhaps a lunch meeting.

These steps would constitute an ambitious program.  Clearly, some projects would end quickly and could be replaced by others, while others would take several years of effort.  If this much activity were embarked upon, one would expect that a major change in the zeitgeist of the practice would result.

The Electronic Health Record

A note is needed about EHR’s, since EHR proponents frequently assume that much of QI would be accomplished it information technology such as EHR.  It is true that many QI steps discussed here as paper-based technologies might be more elegantly accomplished with EHR’s.  EHR might also provide easier chart review, easier use of patient registries, easier reminders of clinical practice guidelines, easier communication among providers, etc. EHR would also force reluctant clinicians to use tools that they might ignore were they only on paper.   No one doubts that EHR is in the future.

Introducing EHR to an office, however, is expensive and risky, and the financial upside very limited.   The contribution of EHR to quality remains in question.  Many desired computerized functions (patient registries, immunization lists, etc.) can be provided by a computerized billing system, already standard equipment in most offices.  Critics wonder why “the doctor should be asked to invest in medical record systems when primary systemic beneficiaries are elsewhere?” It is doubtful that one marginal business case (EHR) will facilitate another marginal business case (QI).  Since most QI steps will be translatable to EHR when they appear in a practice, and since much of what EHR do can be done with paper charts and billing systems if not so elegantly, indeed since QI beforehand may actually facilitate QI after EHR implementation, QI should not wait on EHR’s, and above all EHR’s should not be viewed as a substitute for QI.

Conclusion

While the need for QI is clear, the obstacles are formidable, and the incentives beyond idealism appear weak.  There is no specific road to follow, and few practical measures. Many objectives, however, can be reached rather easily.  It seems clear that if quality is to improve, practices must consider issues of their own organization very seriously.  Despite the current climate of cynicism, medicine has historically been a repository of idealism.  It does appear that if a practice is idealistic enough to want to pursue QI, and if it adopts an intelligent plan, it need not suffer for having chosen to do so, and indeed, might benefit as much as its patients for the effort expended.

A Sixtieth High School Reunion

Did anyone ever think at all, at all, about the prospect of a 60^th high school reunion? Even 50^th ? He certainly hadn't. It just kind of came at him. Class composition is a random event; some are great and close, some just suck. And people take them differently. His wife couldn't get away from her Southern California high school fast enough. An introvert, she thought she had been undermined by teachers whispering to selected students that she was the smartest girl in the class. That wouldn't bother lots of girls, but in that time and that place, it was, she thought, at least for her, the kiss of death. So she asked him about his pending 60^th, “Are there any people you hope don't show up? People you hated?”

“No, not really. I can't think of anyone. When I look back, I'm more self-accusatory than aiming at others. I think about my mistakes, especially people I hurt because I didn't know any better, and things I didn't do right.”

She knew how much he had loved Lower Merion High, how much he loved his classmates, how he still kept in touch with many of them, how many had visited them in Berkeley, how one classmate was nearby and a friend. She knew how much he took pride in how smart his friends were, how collegial, how nice. She knew the legendary poker games. She could guess at the drinking, no doubt. Not going to the reunion would be stupid; he wasn't going to miss that. They had been friends when they were all just starting to differentiate into the beings they now were, but the root must have been pretty firm, because they all viewed themselves as related, still.

He didn't know what was going to happen now, but it wouldn't be riotous, for sure; that was for earlier reunions. He remembered at one reunion years ago, he was at a table with a girl he had gone out to a golf course with one night. “You want to be bad,” she said, and they returned to the car. Now, at the table, she said, “I was so stupid. Pause. How about now?” He hadn't been smart enough to say, “I'm so tempted, I wish I could, but I can't.” Instead he just said no. He had gotten a lot smarter, but still had a way to go. He knew he would always have a way to go.

They checked in at the reception table for the name badges that had the yearbook picture attached. His wife said, “Was that you?” The others were the reverse – they recognized the picture and thought, “Is this you now?” Picket posts of time, the continuous three years at LM, then the reunions. Reunions rekindle, and reunions retrogress. What is still, and what is no more. And increasingly, who is no more. Reunions are extraordinary because they bring together two distant points in time, then and now, what you couldn't have foreseen, what you can't rectify, what was really great then and couldn't be replaced.

All is temporary, all is fleeting, yet some things last, that's the amazing part. While the past is past, he wondered, is it still possible to fix some things, even if he wasn't sure what needed to be fixed? He thought that most people understood his feelings of warmth, and shared them, and that was really the whole story. Nothing had to be fixed.

The first thing he noted was what was missing – anxiety. He had expected that no one would be trying to impress or prove anything, at least not much, the tales had been told. Anxiety is about the future, and at this point, as he liked to say, most of his tomorrows were yesterdays. But what struck him was what he hadn't really realized before, that anxiety had been prevalent when they all first knew each other, but not recognized back then, as fish don't recognize that there is water that they are swimming in. He realized how pleasant it was to be without it.

Here in this hotel that hadn't even existed 60 years ago, he found his expected friends, those people who you pick up with and the feelings are still there, who give meaning to BFF. But then there were the other, random contacts. Blessed with a good, even terrific memory, he casted his mind back without effort and made contact. There was Larry, the ever-colorful Larry, in whose car he had been by the Narberth playground when the great Guy Rodgers came off the basketball court and said, “Hey, nice car!” Larry didn't remember, but he sure as hell did. Close contact with a major hero, favorite player ever (as opposed to best, just favorite, the memories, the flash.) Larry a Beverly Hills attorney – Larry? Larry, for whom a second rate college was too far a reach? Overwhelmingly good humor, such acceptance of himself, a sweetness mixed with gruff extroverted good humor. Surprising but completely in character that he said he had just met Friel, ne'er do well Friel, in Vegas. Vegas, for God's sake, at their age, Jew and Irish, still having fun, God bless them.

The others. Bob who who came up and said hello, do your remember me, and blessed the one school that would take him after high school, blessed it for saving his life, he thought. Strange and wonderful that he would share that intimacy. It was hard to know how to respond to that, but a smile and a squeeze on the shoulder conveyed the warmth.

Walter circulated freely, bring back drinks from the bar for obviously not the first time, newly voluble Walter. Complaining about his waning sex life, at 77.

“Playing any baseball, Walter?”

“I wish!”

“You were a great pitcher.”

Then he got The Look back from Walter, real appreciation. That was the hook for Walter, the best thing anyone could ever say to him. What mattered to him, the golden memory, and to think that anyone not only remembered, but who told him how he admired him. Priceless, said The Look. He noted it, and was amazed, and happy he had come up with it.

The usual set of happy friends, “the brains” said classmates, sat around, but someone new was with them now, Vicky. Vicky, pretty girl who had had, could we say, a “good figure.” Who had been George's girl friend but they hadn't survived as a couple. He had gone to Michigan State, but when he asked her where she had gone, maybe Penn State, she kind of deflected and said how she had gotten hooked up with a Jewish guy (she being of Italian heritage), and moved to Israel for a while with him. Must have been fish out of water, but you just never know. She now had all the reminders of how pretty she had been. Funny she was here with the others who, as far as he knew, hadn't been her close friends then, but everyone still referred to her with the one name, Vicky, and everyone was glad to have her. Was she more connected with everyone than he realized? He guessed he still didn't understand everything about class structure. Although with time, he knew, if through nothing else than through Romy and Michelle (underrated!), that the smart people get more prestige at reunions. But here was Vicky, from the popular clique, somehow mixed in and everyone not surprised that she was there, just mixed in. It was sweet.

They told him that he should go say hello to her because she lives close to him in the Bay Area. They eventually met, and he introduced her to his wife, telling her that he didn't know if Vicky knew it or not, but all the boys had looked at Vicky with a certain longing. Vicky turned away but in doing so, gave him That Look. “Did they really?” she thought as she stammered something else. The same smile that Walter had given. Was that connected to her suggestion later on, when they were alone, that they get together back home? “Absolutely!” he responded, but knowingly failed to exchange phone numbers.

He remembered the time when he and his wife had run into Bruce, a graduate school classmate at Berkeley, who turned to his wife and said what a terrific basketball player her husband had been. His wife replied to Bruce, “You couldn't have said anything else that would please him so much!” He thought that what she had done was to give The Look by proxy.

How many thought at the 60^th, these are our real roots, the real friendships, the earliest that are true? He didn't know, but the warmth was very real.

Then there was such a surprising connection. Angela has been a constant friend of his close friend, Lynn, in New York. They drove over together for the event. She had gone to Bryn Mawr College – he remembered that – and majored in French literature – of course he didn't know that. Then had gone on to grad school in French Lit at Yale, then taught French Lit for years at Sarah Lawrence. Then they talked for the longest time. He told her his theory of Madame Bovary, with what he thought might be a feminist interpretation, and how much he liked The Red and the Black, and she responded with verve and vigor and interest and passion, and they both discovered, unexpectedly, their common interest. She told him a basic book to read (Mimesis, by Auerbach), which he ordered immediately. She told how she hadn't been around in high school for all the social stuff because her parents were in the midst of a world-class toxic divorce, and she lived with her mother an hour and a half away, and how she was upset most of the time. Both mind and body were elsewhere.

How did their relationship start, he asked Lynn? She said that they were in the same homeroom and their last names were close so Angela sat in front of her, and how Lynn went through all the sturm und drang with her. He hadn't heard anything about it, only that Angela's mother wound up marrying Claude Rains years after the divorce. Angela said Rains was a difficult man with a difficult Cockney background, and told the story of how he was chosen by George Bernard Shaw to star in the only film version of one of his plays. He was called to meet the great man and was appropriately respectful and self-effacing. Shaw took the whole time staring into the fire and stoking it, while Rains stammered behind him. As the meeting came to an end, Rains, thanking him profusely, observed that meeting him for the first time was a thrill. With this, Shaw finally wheeled around and told him that this wasn't actually the first time they met, and asked him if he knew why he had chosen him for the lead. Rains had no idea.

Shaw asked him if he remembered the first time they met. No, no idea. Do you remember when there a man who was suddenly taken sick in the boxes during a show, and you were called to help, and you went to the other side of London to get a doctor and bring him back? That man was me. And I've been looking for a chance to express my appreciation since then.

Or so he remembered the story, as told by Angela. He wondered how frequently it happens that new friends are made at 60^th reunions. He, old and dear friend Lynn, and newly dear friend Angela, sat together on the deck for about an hour as the event came to an end, departing people walking past them and saying goodnight, and were very comfortable.

So much had happened, and was still happening. John's daughter is suffering from a recurrent brain tumor, using the new immuno-therapies. How does anyone stand that? This excellent man has to contend with this most difficult and unfair attack by nature, and it showed, strong as he is. He remembered when John's Mom and Dad were divorcing when John was in college; he remembered when John's mom was dying of ALS. As they spoke, John became even more impassioned than ever. John reached out to him, old friends whose appreciation of each other has only grown. John told him that he was probably the one person who got him best, who said things that mattered. He told John that he did get him. He knew about John that, in a group of people, John would be the one who identified the one who needed help and would try to give it to him. It had taken him a long time to realize this, even though it was John who inevitably reached out when he needed help when they had been roommates in college, but he now saw it so clearly. John had been king of the high school class, the inevitable class president, and he had always been a good one. Now, in older age, the appreciation only increased. John still tried to help everyone he could. He was even driven by this. They held hands briefly at the table as others looked on.

The non-locals who had stayed in the hotel overnight met for breakfast at a long, wooden table in the dining room that had been opened only for them. He felt the love they had for each other, all of them, knowing they were coming to the end together as they had started out together. Lorraine had said that this would be the last reunion, but maybe not, huh? He said to the group, maybe make it three years, as time is running out. Old, dear friend Bill, who had sprouted 6 inches one summer and came back a center rather than a guard, a great poker player not inhibited by excessive feelings for the pain of others, stood up at the end of the table to leave and go back to an event at home in Virginia. He wasn't going to let Bill get away with that; he got up and walked around to very tall Bill and gave him a big hug. Surprised, but delighted, Bill bent his legs and returned the hug with brio. Not to be outdone, short but solid Bob also got up and came to hug Bill, which was harder, since they were about one foot different in height. They wound up theatrically kissing, from close and afar, to the amusement of all the good and old friends.

Doubtless others felt differently, even though turnout was excellent there were many missing, but for those who were there, at this time and this place, he felt that there was a satisfaction with themselves as a group, with one another, with their connection, with their joint history, with their fidelity to one another. Such times are rare. They are the lucky ones.

Budd Shenkin

Joe Biden Needs To Respond To The Trump Challenge

Joe Biden is ahead in the polls, but he still has a way to go to seal the deal.  If his prime qualification is winability, he will have to show that he can be a strong and declarative candidate, not just good old lovable (and stumbling) Uncle Joe. To get the nomination, he will need to show that he can make strong arguments, be adept, perhaps even subtle, but strong and even close to eloquent. In any event, convincing and persuasive.

So if I were to advise Joe, I would tell him that now that he has appeared in Trump's crosshairs, it is a prime opportunity for him to show his mettle – can he pivot and take the case to Trump, run against him now?

So here's a  version of the speech I would advise him to give.

The Speech

I have a son, Hunter, whom I love very much. He's not a kid anymore, he's 49 years old, but I don't have to tell parents out there, no matter how old they get, they're still your kids, and you never stop loving them. You don't approve of everything they do, they don't listen to your advice, but they are your kids, and you love them, and you give them your unconditional love.

Hunter has come under into the crosshairs of the great machine of destruction called Donald Trump. Obviously, Trump doesn't care about Hunter, he's trying to get to me. He and his minions are accusing Hunter of taking a position as a member of the board of directors with a Ukrainian energy company, and in that position, using his connection with me to make money for that company by getting contracts for them with the United States. I guess that's his charge, Trump is never that clear as he rants and raves. He just says, “It's dirty.”

Should Hunter have taken this position? It was legal for him to do it, he did nothing unethical or illegal while he was in the position, and he was well paid. But, I'm sure the fact that he carried the name “Biden,” and that I was Vice President of the United States at the time, helped him get appointed to this job. Let's face it, when your father is Vice President, you get offers you wouldn't get otherwise. He didn't ask me about it, and I didn't give him any advice, and his company didn't benefit from their indirect connection to me in any way that I know about.

But now Donald Trump can't leave that alone. He's got to find something wrong and bad, and if he doesn't find it, that doesn't matter to him, he makes it up anyway, makes accusations, lies and impugns and smears and does as much harm as he can, just because that's what he does.

You have to hand it to Trump. He really is a genius, not a stable genius as he claims, but he's a genius of destruction. If there is a person or an institution that gets in Trump's way, or even just gets near him, watch out! And now he suspects that I will be in his way of securing a second term, and there is my son, Hunter. Trump figures that Hunter is fair game, because to him, everyone is fair game. John McCain was fair game. If he can slime John McCain, surely he can slime Hunter and me. To him, he is the only person in the world who exists.

Since this attack is on me, even though he is using Hunter as a ploy, I am the one who needs to respond. That is what I intend to do. First I will respond directly to the charge, and then I will take the challenge that Trump seems to be issuing, and address corruption in government, most specifically, his own. And then I'll add a few words about the destruction that Donald Trump has brought to this country.

The Charges Against Hunter And Me

The basic charge that seems to be leveled at us is that Hunter took this position and then used his connection with me to the advantage of the company. Trump also says, what was Hunter doing in that remunerative position when he has no obvious qualifications. Let me answer those questions.

Well, it's well known that Hunter has had a tumultuous life, starting when his mother and sister were killed by a runaway driver in an auto accident when he was not yet three years old. Since then he has achieved many things, but he has also been wracked by demons, including drug addiction. To his great credit, Hunter has been up front about this. He bared all for a magazine article in the New Yorker. And as he has had his severe problems, Hunter has benefited from his association with me. Others have been there to help him up. In truth, although Hunter is a bright and capable person, this position that Trump refers to, is in fact something that he would not have gotten save for his association with me. Children of people in high political office have avenues open to them that other people don't, and they often take them. This is unfair. Life gives advantages to some that it denies to others. I recognize this, and I hope that people will look at the record of what I have tried to achieve in life and realize that I have sought all my life to give the advantages to others that the rich and well born, and public officials such as myself, already enjoy.

Should Hunter have taken this job with the Ukrainian company? If he had asked me, I would have said no. He made a lot of money for it, and it was very tempting and I understood why he did it. It was an opportunity for him that helped him out financially, and he knew that he would not do anything corrupt. Nevertheless, I would have told him, find another way. But he is in his 40's, and he's got to figure things out for himself.

But the most important thing is this, not whether or not he benefited from his family connection to get this position, but rather – were the interests of the people of the United States compromised by his taking that job? My answer is simple – no, no, not in any way, never, a thousand times no. Hunter never contacted me, directly or indirectly, about any of his business, and I would never have listened if he had.

But, you don't have to take it from me. There have been several investigations, they have been deep and thorough, and they have all come up with one conclusion. There has been no fraud, no influence, no corruption as a result of Hunter's taking this position.

Trump and Corruption

Donald Trump is, as we know, a terrific liar. One of his greatest talents is to take what he is guilty of and attribute it to others. He did this most jaw-droppingly obviously and publicly against Hillary Clinton in one of the debates. She accused him of being a puppet of Russia – a charge that we have seen to be totally true, of course. But what did Trump do? He turned on her as a not very bright bully in the schoolyard will, and he said, “You're the puppet!” Unbelievable – Hillary, a puppet of Russia! Believe that, and there's a bridge he's like to sell you. But, it was so breathtaking a lie that it was hard to counter. We are used to people trying to saying things that are at least somewhat truthful, but this was just breathtaking.

But what I'm pointing out is this: look at the technique – take your major flaw and attribute it to others, even if it couldn't possibly be true. That's what he does, and that's what he is now doing to me. Me, corrupt? I've been so uncorrupt that for virtually all my life in the Senate, I was the least-wealthy senator. I had to mortgage my house twice to send my kids to college. Look, is this what millions of parents do every year, I'm not complaining, I'm just saying that if there's anyone not corrupt in public life, it's me.

On the other hand, let's turn the spotlight where it belongs, on Trump, his family, and his associates. There has never been a family or an administration in the history of the United States that comes close to the corruption of the Trump Abomination.

Most people assuming high office in the country forego any further profit. They are working for the country. Not Trump. Money is his God. He has given up none of his holdings. If you want a meeting with Trump, you stay at his property. If you are a government wanting access, you rent out floors in Trump properties. If you are the military, you schedule your troops to fill up their planes at Trump filling stations, you put your overnight stays at Trump properties.

The Trump family is the most acquisitive, values-free family in the history of the Presidency, bar none. No one comes close. If you are China, do you want to do business? Grant Ivanka licenses and copyrights. A Gulf nation wants to do business? Grant Jared a $90 million cash infusion.

[Biden should insert here a list of the items of corruption – there's so much, one has to choose only highlights.]

So, Mr. Trump – you want to call out Hunter on his judgement? You too, Mr. Giuliani? Let's go at it. You have a pair of deuces, and I have a royal flush. You are a bunch of corrupt liars, and you have no business running this country, because you are running it into the ground.

The Trump Slime Machine

Corruption is a disease that eats its way into the body of the country. We shouldn't allow it to happen, and I have faith that we won't. But just as vicious a vice is the lying. Trump and Giuliani have such warped personalities that they don't care. They just take dirt and throw it around. Truth? Truth is for suckers (like paying taxes, as Trump has said.) The lie is the thing, keep repeating it until it becomes fact. This is the Trump modus operandi, his MO. Even though everyone knows this, Trump's genius is not to care. Trump is out there ruining the good name of this country, making the country a laughingstock internationally, giving away America's largesse to other countries who are not our friends, dirtying our name, and getting away with it by lying, lying, lying. If you like to lie, if it is second nature to you, if you do it repeatedly and effectively, if you do it loudly and incessantly, and if you are in a position of responsibility, there is no limit to the damage you can do.

This is the truth that Trump's lies have taught the world.

So, to finish this up, Hunter has his weaknesses, just as I have mine, and just as all of us have ours. But most of us try to do the best we can, to honor ourselves, our families, our country, and try to be the best people we can be. I doubt, though, that we can say this about Donald Trump. He is just a scourge, and he glories in being that.

One of the most important things I can do for the United States, the country I have loved and served for all my life, is this: I'm calling out the Trump lies, and I'm asking everyone to pay attention to them. Don't overlook them, and don't laugh at them. Take them seriously, and reject them, and reject him for who he is and for all the bad behavior he glories in, all the destruction he purveys. Realize that these lies and this liar are bad for us as a nation, bad for every single one of us.

We need to find the truth that will set us free, and the truth is that Donald Trump's lies can lead us to our destruction.

Budd Shenkin