ICU Doctor Feels Guilty, But It's The System, Baby!

WHILE IT'S TEMPTING TO CONCENTRATE ON INDIVIDUAL ACTS, IT IS MORE ELUCIDATING TO EXAMINE THE SYSTEM THAT BROUGHT ABOUT THE CONDITIONS UNDER WHICH THE PRINCIPALS WERE ACTING. 

 AN ICU DISASTER CAN BE SET UP BY A MALFUNCTIONING SYSTEM THAT SHORTCHANGES PRIMARY CARE.

 

 

“‘You’re Dying,’ I Told My Patient. I Wish I Hadn’t.”

That's the title of the New York Times article by Daniela Lamas, an ICU doc at the Brigham and Women's Hospital in Boston. (My old digs. I used to lug my laundry through the Brigham lobby to get to the dry cleaner on Huntington Ave. Never made it to the ICU, though.) One night in her ICU, Dr. Lamas found herself caught in a real dilemma. One of her patients was a strong-willed man dying from untreated colon cancer – untreated, she says, because, “Colleagues at the hospital had called him to schedule appointments, to get follow-up and to start chemotherapy, but he never responded.” Still in denial about his serious illness, he told the doctors that he simply wanted his pain treated so he could go home and watch the game. Dr. Lamas saw her dilemma as this: should she be kind to the patient and lie to him that he would be going home soon but he had to stay the night; or should she tell him the bald truth, that he was too sick to go home and in fact would probably die that very night. Kindness and a lie vs. cruelty and the truth.

Uncharacteristically for her, she chose the path of telling the bald truth, probably with controlled anger, it seems from the tone of the article. She admits that she was frustrated, and says that it was because of “the avoidable nature of this tragedy, at how denial had turned deadly.” The patient's rudeness and aggressiveness must have taken its toll, although she doesn't cop to that human reaction. The patient's response was to brusquely order the doctor and her coterie of students and trainees out of the room, and two relatives (the author takes care to specify that his sister who came was “long estranged”) stayed with him, and to turn on the game. Later that night, he died.

She devotes the bulk of the article to berating herself for acting badly, not kindly and softly, against precepts that she knows and accepts, and which she recounts for the benefit of the lay reader. This traditional medical dilemma is clearly what Dr. Lamas wants to article to be about. It's always a juicy subject that non-physicians can relate to. I've dealt with this myself, – see my blog Death And Other Bad News, where I recount some of my own dilemmas, and I present a case report where a doctor wasn't told his own fatal diagnosis by a long time doctor-friend taking care of him and how betrayed he felt, and where I suggest that medical students should be exposed to experienced doctors handling end of life situations in the very first month of medical school.

She berates herself for not being Ms. Sweetness in dealing with this obnoxious patient on this awful night of culmination of an awful disease, but at least she was genuine. Who wouldn't be angry and frustrated, given the situation which wasn't her fault, but had certainly become her problem? Who can shine when two strangers meeting at the worst time possible, and she had miles to go before she slept?

In her analysis of the situation, she intensely examines her behavior in responding to the challenge, self-dramatizing her challenge and her doubts in a very personal way, reflecting how we used to think of doctors, as heroes on a white horse riding to the rescue, wondering if she measured up, and bravely diagnosing that she didn't.  Her intensity is both her strength and her weakness. Being so concerned about doing the right thing and knowing the details of what you are supposed to do speaks well of her. On the other hand, the more deeply she looks into the awfulness of the night, the narrower her focus becomes. She would do better to acknowledge her understandable feelings and reaction, and then to look more widely.

So to me, as a health professional used to looking at systems problems and quality of care, her discussion misses the mark. Medicine has done well in finding a way to investigate errors. We are used to going back from the error to assessing the series of events that led to it, ultimately hoping to find the root cause. How did this truly awful situation, where the last night of a patient's life is spent in an ICU where the doctor and the patient are meeting each other for the first time, and where the patient is resentful and distrustful, how did this awfulness come to pass?

The first clue is Dr. Lamas’s statement that “Colleagues at the hospital had called him to schedule appointments, to get follow-up and to start chemotherapy, but he never responded.” Really? Someone had made the diagnosis, someone knew he had to come in for treatment, and the only effort made was calling him repeatedly and then ignoring him when he didn't respond? That can't be the whole story; Dr. Lamas must have needed to keep the article short and focussed. In California, if you order tests on a patient and he or she doesn't show up for it, you as a practitioner are legally responsible to have made a truly vigorous and well-documented effort to have the patient complete the referral. A few phone calls would be impeachable in court, I think. It doesn't seem fair to be required to do this when you are in practice, but if you think about it, it really is. Who else can take care of the patient?

So, failure to force follow-up is one source of system failure. Why did that occur? Who were those primary care providers, or the specialist providers who assumed care of the case? Were they an impersonal hospital specialty clinic with students and fellows and residents rotating through, with staff detailed to make calls, nothing really from a practitioner, nothing personal, nothing from someone that the patient knows? A private practice that was disorganized, or who didn't have a close working relationship with the specialists and the hospital? Who was in charge? Whoever and whatever it was, they failed the patient, even if he were difficult, even very difficult. Was there no special outreach available at the Brigham, no social service, something? After all, there was a man dying out there, and they were responsible. There is always another step to take.

In this complex system, there always has to be someone assigned as the chief responsible party. Did that happen here? If there was not somebody riding herd on the progress of the situation, why? Was there a plan, or was it to make the calls and it's off my plate?

And then, one more step back. Before the patient came up with colon cancer, where did he get his care regularly? Did he have a regular primary care physician, or nurse practitioner, someone that he had grown used to and to trust over the years, someone to turn to, in private practice or in a clinic, with one doctor or nurse practitioner primarily, not trainees and staff rotating through? If he did, was there no coordination between the primary and the specialists, after the specialists were supposed to take charge?

All these factors are specific to the patient. But, in our search for root causes, we can go even one step wider and deeper. Perhaps the real heart of the matter is the failure of the American health care system to emphasize and to support primary care properly. Among the health care systems of much of the world, the US is an outlier. We emphasize specialist care and under-resource primary care, both with numbers and money. Many patients go without regular primary care, let alone a clinician who cares for them properly and who they in turn rely on and respect. In the hospital, even though it is known that best outcomes often come with the involvement of the primary care doctor – not taking the whole burden, but visiting, interpreting, giving the caring part rather than the curing part of medical care. Yet, these days, finding a primary care doc in the ICU is rare, and indeed, even in the non-ICU parts of the hospital, primary care docs have essentially been banished. Hospitalists take care of the hospitalized patients. And with hospitalists, although things can go well, it is essentially strangers involved in a new relationship, if it can even be called a relationship. And relationships between primary care and hospitalists are often problematic, and even if they are good, the presence of the ongoing caregiver is still missed. Payers don't want to pay for these visits, they are financial losers for the doctors, and hospitals and their clinicians really don't want the primaries around. No one thinks about the doctor patient relationship and the feelings of the patients. No one speaks for the patients.

(In fact, to go a little further afield, you have to wonder if the widespread COVID vaccine refusal phenomenon has a lack-of-primary-care route. There are a lot of potential culprits – misinformation, distrust, politicization. But, is it too farfetched to think that if more people had good primary care relationships, trusted people that they could turn to, and ways to ask him or her their advice easily, many fewer would refuse?)

There is also another deep root cause to think about. Since this is the Brigham, we are in the heart of corporate medicine land. Corporate and bureaucratic entities, most of them monopolistic or oligopolistic, are marked by confusion of jurisdiction, mal-coordination, and worst of all, lack of primary care fiduciary responsibility for the patient. It's easy to disappear in a bureaucracy. (For more on centralization-decentralization, see my acclaimed and innovative 2017 blogpost.) The more corporatization and bureaucratization there is, the further away the patient is from the caregiver, the more phone trees there are, the less personal connection, the further the organizational decision makers are placed from the receiver of care. So, saying that bodies (doctors and nurses and students and others) will be ready in the ICU to care for another body (the patient) may well seem adequate to a corporate planner, but when the actual patient encounter takes place, the lack of a personal trusted relationship makes itself finally felt.

My friend Phil Polakoff says: Words are important, acts are more important, but relationships are most important. You can train people to say words and perform acts, and they may or may not do it, but you can't graft relationships onto personnel the patient doesn't really know.

And eventually, the root cause approach takes us beyond the medical care system. Where has this poor man fit into society? Who takes care of him? Does he live alone? Is he one of those who can't fit easily into society, who is marginalized, who suffers the consequences of isolation? Where are the social supports? Even if he was a person of great personal difficulty, as Dr. Lamas seems to imply, someone who has brought much on himself, it is still tragic to see this as the final scene in his life.

To get back to the doctor's ICU dilemma, what do you do when the system disserves you, when something that isn't your fault becomes your problem? That was Dr. Lamas's lot in her scenario. But her presentation deals only with individuals – the patient's culpability, “people who are dying because of bad decisions about their health,” and her own personal missteps, the doctor as hero on a white horse. But today we think about systems, and she could do well to think, I have been placed in this place and this moment because of the decisions of many others, many of whom are too distant from this place where the rubber hits the road. Decision makers need feedback. A system that places strangers together at the very end of life is not humanistic enough. And then she would ask – how can I help the system improve? It wasn't her fault but it was her problem and she did as well as she could, but what could be done for the system to stop setting such a trap for both patient and doctor?

Despite Dr. Lamas’s mantle of regret and even guilt, it's pretty obvious that both doctor and patient were victims of our system, which undercuts caring, which relies on big organizations where the caring function can easily be lost, and which favors specialists over primary care givers. This awful result and the awful process of that awful night must be repeated everywhere and every day, which is a great shame. (I had thought of titling this essay “An ICU Doctor Misdiagnoses Her Own Problem,” but then I thought that was probably too harsh, she just concentrated her writing on a narrow problem that would sell, rather than a larger and more abstract one that would be less popular.)

So when her essay was published and I had the thoughts I have just outlined, I wrote a necessarily compact letter to the editor, which they published in the Sunday editorial section, along with several other letters which concentrated on the dilemma as stated by Dr. Lamas, while I, of course, concentrated on the system.

To the Editor:

Every doctor can sympathize with Dr. Daniela J. Lamas’s mea culpa for feeling she didn’t handle well the perpetual dilemma of terminal disease and professional frankness. Looking deeper, however, it seems that her dilemma was caused by failures elsewhere in the system.

The patient “never responded” to calls to schedule lifesaving treatments? That’s it? He didn’t respond to calls, so not our problem? Where was his primary care doctor, if he had one, and if he didn’t, why not? A trusting relationship with a primary care doctor can make all the difference in getting patients to treatments. Where was the teamwork among medical professionals?

Dr. Lamas’s anguish is understandable. Understanding the root cause of her dilemma might empower her and her colleagues to work to fix a faulty system.

Budd N. Shenkin
Berkeley, Calif.
The writer is a retired pediatrician.

Budd Shenkin

Adam Schiff On The Peril Of Our Time

 

When Trump emerged, we awaited eagerly the demise of the uncouth fool. We're still waiting. For every month that goes by, the question of “who's the fool” is batting itself around like a beach ball in the stands of a ball game.

It's one thing for the largely ignorant but massively resentful “base” to keep the ignorant, uncouth fool alive, but who would have believed the constant resuscitation by a thoroughly transformed and disfigured Republican party? Former believers in Republican cant have felt the scales fall from their eyes as Republican politicians desert their professed principles and kowtow to Trump. Despite my viewing Republicans in congress better described as paid agents of large corporations rather than as true representatives of the people, I have to admit, it's a shock.

Stuart Steven's book title captures it succinctly: It Was All A Lie. But the surprise is not only Republican. In his terrific new book, Midnight in Washington, Adam Schiff recounts his shock, as Republicans he liked and even admired so readily shed their professed beliefs like the snakes they apparently are. Rather than believing Lord Acton's saying that power corrupts and absolute power corrupts absolutely, Schiff prefers Robert Caro's formulation that power doesn't corrupt so much as it reveals. He could also have quoted Lincoln, who said, “Nearly all men can stand adversity, but if you want to test a man’s character, give him power.”

As he told Kara Swisher last Thursday:

“Most of my Republican colleagues do not believe the big lie. They know it’s a big lie. And yet they push it because they’re afraid of Trump, because they’re afraid of a primary, because they want to advance to the Senate or maybe they want a cabinet appointment in another Trump administration. And it turns out nothing is quite as important as that. Not their oath, not their ideology, not what the party used to stand for. And that was a terrible realization for me.”

In any case, his blinders removed, Adam Schiff has found himself in the ring contending with the largest revolt against our constitution in 170 years, and he is well aware of it. As one of the most thoughtful and articulate of the resisters, he is well worth paying heed to as he recounts his trials and tribulations and thoughts and fears.

My thought is, what a hero Schiff has been, especially leading the first Trump impeachment, especially standing so strong against the Republican lies and all their mishigas! So when I was invited to a breakfast fundraiser last Friday for Adam (I'm going to call him Adam, because he did call me “Budd” at the fundraiser, so why not?) at my friend Doug Goldman's house, I was thrilled to go. I wanted to see if he had anything new to say to the small breakfast group, or at least to see him in the flesh and get him to inscribe my copy of his book, which I was lucky enough to get on the first day before they ran out at East Bay Booksellers. Going to see a hero in a small group is not a small thing!

So, as I got ready to go to the breakfast, I had to think through the subject at hand. Of course, it's no news that a slow coup attempt is under way, even the late adopters see it now. The major popular theoretical texts are Levitsky and Ziblatt's How Democracies Die, and Timothy Snyder's On Tyranny, I guess. Then, filling out the theory with events, the autocratic-leaning steps that Trumpists and Republicans are taking are being documented by a spate of books by participants, including Strzok's book I reviewed, Leonnig and Rucker's book, Woodward and Costa's Peril, and now Adam's book as well. (Mary Trump's book, tracing what it takes to be world class sociopath, which I reviewed, is also first class in many ways.)

It's one thing to understand and describe what's going on, but it's another thing to act. What is the country, led by the Democrats, going to do about it? At this point, it isn't clear, at least to me. Of course they will try to win the midterm elections next year and, contrary to historical pattern, increase their slim margins in House and Senate. Adam says that they actually will have a chance at that, because the Democratic majority is not a bloated one, since Biden had no coattails. But, the question is, how exactly are they going to do that? By passing excellent and transformational legislation, thus earning the votes of right-thinking and grateful Americans? By having excellent candidates to run on kitchen table issues, similar to the “preexisting conditions” campaigns of the recent past? Or will they break that pattern and nationalize the elections, trying not to run on what a good guy Biden is and how well he has done and what more he can do with a good majority, but instead run against Trump and Trumpism? Or maybe do both?

And underlying that question of strategy, what are they going to do with the blatant and defiant attempts of Republicans to corrupt the process of elections, the state gerrymandering and voter suppression legislation, the substitution of legislators for impartial officials to supervise the elections, and the attempted installation of fifth columnists ready and eager to declare slate of electors invalid and to install their own? Add to that the physical intimidation of honest officials trying to do their jobs, and traditional election strategizing seems passé.

So, these are questions I've had in my mind, and I wondered if I could get any insight into them at this hour long breakfast. I kind of doubted it – I expected the “here's what we are going to say to our supporters” talk from Adam. But anyway, because I'm not particularly fast on my feet orally and I'm not a great questioner who can follow up well, I figured I might give it a try by writing down a question or two. As Tom Lehrer advised, Be Prepared!

I started by writing down a bunch of questions, and then I culled it down to one long question that I would hope to ask. Here are the questions I started with, and then the one I decided on.

The Danger of Subversion Within The Ranks Of Law Enforcement

Make all the laws you want, if they are not obeyed, they then need to be enforced. Can we be sure of enforcement? Police departments are full of right wingers, prejudice, and rebellion under the leadership of openly defiant police unions. Even if formal leaders are in line, will the troops follow their orders, or follow Trumps on their own volition? ICE and CBP have shown authoritarian, prejudicial tendencies. Where did the un-badged enforcement troops come from in Portland and Lafayette Square? The military does seem to be OK. Not sure about the courts with all the Trump appointees, many openly advocating rebellion against Roe vs. Wade, for instance.

What will happen if insurgents in states and localities take control fraudulently? Courts order, maybe – there are bad judges – and then what? Who's really minding the people with actual physical force? Consent of the governed is fine, but behind that consent is the state monopoly on violence. What will happen if that monopoly breaks down?

In short, it would appear we have every reason to be worried about enforcement. Is anything being done?

DOJ Avidity To Prosecute

Many people (including me) wonder where Merrick Garland is on the question of conspiracy to subvert the 2020 election after the vote, and on high-level leadership that led to January 6. Publicly available evidence seems clearly to indicate that Trump and others worked together to subvert democracy. Shouldn't the DOJ be working very hard to investigate this case? Are they waiting for the House committee? Is there reason to wait? Could a lot be happening there that we don't know about? Are you concerned that they will place a higher priority on making DOJ look “impartial” than on saving democracy from subversion by Trump and Republicans?

Why are recommended sentences for capitol assaulters so light? Because all they have is “trespassing?” Is it true that DOJ has 3 levels: those who were there, those who attacked police, and those who planned? Are those who flipped indicating higher ups, of whom some could be prominent? What about inciters speaking to group before they moved down Pennsylvania Avenue?

I posted this on Twitter and got interest:

“What is behind these "take it easy on them" recommended sentences for assaulting the capitol? I guess the law doesn't cover intended insurrection well? Just get them on "trespassing?" A puzzle to me.”

Do you think DOJ is actually prioritizing the capitol assault and the plot against America, and we just don't see it yet? I'm going to fundraiser with Adam Schiff on Friday, hoping to get chance to ask him. Looking for nod and wink.What is your level of confidence that the DOJ will be acting decisively? Is it above level 5 out of 10?

The Problem Of Widespread Treason

It's pretty clear that many high officials are guilty of treason. Indeed, you could say the whole Republican party falls into that description. Ziblatt and Levitsky currently comment:

“We did not expect that the entire Republican Party would evolve into an anti-democratic force, and that’s where they are today,” he said. “The entire Republican leadership, with a small handful of exceptions, is now no longer willing to accept electoral defeat.”

What is the preferred course of action? What do you do when it stopped short of armed insurrection, in the main, but there is widespread unarmed insurrection? Cheating and stealing elections is insurrection, isn't it? Truthfully, every senator and representative who voted against certification were treasonous. Some did much more than that. You could say that a public official's failing now to support the validity of the presidential election certainly violates their oaths to support the constitution. At the very least they should be barred from holding public office for ten years.

These are the kinds of things one contemplates after an armed insurrection has been put down. But what we are facing is unarmed insurrection, with some exceptions. What is to be done?

Public Understanding Of The Stakes, Of What Fascism Is

Adam Schiff's TV appearances have emphasized his confidence that the good sense of the American people will assert itself eventually in rejecting Trumpism. Of course, we have thought this for six years now. What is Rep. Schiff's strategy of reassurance here? Is he secure in what is being done? We need the “time will come” to come pretty damn fast.

Do you think the people of America don't understand our current constitutional danger, or officials? Or the Democratic party? So many are saying, don't you realize how dangerous this is? And yet those same talkers, what are they doing? Lawyers lawyer, talkers talk.

When faced with possible insurrection by a highly motivated minority, the alertness and alarm of the majority, and the majority leaders, is crucial. How does one alert and inform the public? The media are important, but unreliable, and are not sufficient. Greg Sargent in the Washington Post says:

'The White House, too, must lean into the threats to democracy to keep the media from losing interest. Failing to educate the public about the concerted effort to overthrow our democracy and ignoring the connection between election subversion laws and the threat of future coup attempts would be a gross dereliction of duty. Let’s hope the media understand that “fairness”and “objectivity” do not mean helping make Republicans look less crazed and dangerous than they truly are.'

The “good sense” of Americans needs some help. The decline if civics teaching has helped people to know nothing at all about our government as well as foreign governments. The details of fascism escape us. How will people find out, so that they can assert their good judgement based on facts? They need to be told and shown – who will do this work?

My suggestion is this: We need TV specials, perhaps Ken Burns style, or inspired by How Democracies Die by Harvard's Levitsky and Ziblatt, or On Tyranny by Yale's Tim Snyder. This is what fascism looks like, the thugism and the repression, and here are the steps other countries took in getting there.

(Personally, I would also encourage a special bipartisan commission addressing itself exclusively to the issue of democracy, and not considering the substantive political issues (immigration, wealth distribution, etc.), whose mission would be exclusively to educate the public to this vital issue.)

The Possible Progression of Events – What Could Happen

What do you think will happen if there is actually a steal, or if Trump actually wins and starts to institute fascism? Who won't recognize Trump Part II? Will taxpayers refuse the IRS? There will be organized resistance – what then? The “unthinkable” should be made thinkable now. It could happen.

The Responsibility of Democrats

Finally, to the Dems this issue of Trumpism is the kind of thing companies commonly face: Trumpism isn't your fault, but it is your problem. And maybe it is somewhat your fault – haven't stood up sufficiently against wars, deindustrialization, and other social maladies that have helped to fuel resentments. But the underlying problem of undoing racism and the change of power from an ethnic group that is resentful (“I might be poor, but at least I'm white”), that's what makes Trumpism so powerful and dangerous, and that's the Democrats' burden, but not their fault.

Then – what was a practical question I could ask Adam if I got the chance? Here's what I came up with:

I'm halfway through the book and I'm really enjoying it. I especially like the humor and warmth – sitting with Dick Gephardt and realizing that Adam and Eve are sitting with Dick and Jane, and your irrepressible son, and the love of your family and friends. I can see you don't take this gift for granted.

You are unbelievably eloquent when you need to come up with spontaneous reflection. In the House when challenged by Republicans who think you should quit, you perorate with a listing of the transgressions and say, “I don't think that's OK.” And the brilliant summary of the First Impeachment when you say, yes, he's guilty, but is it sufficient reason to remove him? So moving and brilliant.

My question is this, however – when does a strength become a weakness. Lawyers lawyer, and brilliant talkers talk brilliantly, but sometimes using words is not enough, sometimes using words is bringing a knife to a gun fight. There are people out there who are thugs, and thuggery is the essence of fascism, and that's our threat. And we know from Ziblatt and Levitsky that the highest conditions of threat to democracy is when the dominance of an ethnic group is threatened. So even though I don't think that we have essentially revolutionary conditions in the country, it might be closer than we think.

So my question is, while you are confident that the American people will wake up and assert their essential goodness and belief in democracy, how sure are you? Are you sure that the people really understand the gift of democracy? Are you sure that when you and Marc Elias win in court, that the police, riven with right wingers, will enforce the courts' orders? That there won't be a mobilization of the same troops who appeared unbadged in Portland and Lafayette Square won't reappear all over? Are you sure that right will conquer might?

Since I was coming from the East Bay going to Pacific Heights in San Francisco and didn't know what traffic would be like, I got there early. The breakfast was being held on the generous-sized patio just below Doug's front door with about 10 small high tables, and since Adam was right on time, I got a chance to talk to him, have him engrave my copy of his book, and to give him my typed out question. What luck! 

 

He took some time reading it closely, and I apologized for it's being long, but he said, no, you have really thought about it. And then his main answer was this: He trusts that the American people will come to their senses, that they won't throw democracy away. Interestingly, this is pretty much what Leon Panetta said at the Goldman School of Public Policy conference on my paper about Post Trump Reforms – at the end of the day, he doesn't see Americans trading in 230 years of democracy for this schmuck Trump.

I was animated in responding to his confidence (that's a problem when I question or comment with high ranking people, I get animated.) I protested that the American people don't know enough about fascism, they don't know civics, or history, and what we need is something like a Ken Burn's documentary about fascism in Argentina, Turkey, etc. - not just the Nazi's – and something on How Democracies Die and On Tyranny. Adam looked at me and my animation, and didn't really reply. Maybe he was thinking about what I said. I don't know. I mean, if you trust the American people and then reflect on what they know, there might be a disconnect. I do know what he thinks about this, though, because here is what he said the day before our breakfast in an interview with Kara Swisher:

Well, I think part of what resonated for people is — in the last 30 to 40 years, the middle class has become increasingly at risk of falling apart. And people are most willing to rebel, to bring about a revolution, not when they are most impoverished, but when they feel they are most exposed to losing what they have. And he saw around the country millions and millions of people who had had a Bush as president, and their life didn’t change. And they had a Clinton as president and their life hadn’t changed. And he said, I’m going to break everything. And they were ready for somebody to break everything. And they didn’t necessarily believe he was going to improve their lives. But at least he was sticking it to those that they thought were responsible for their circumstances. So I think that was part of the appeal. And an enormous part of what my party needs to do. We need to show that the democracy can work and can deliver for everyone. We could create an economy that works for everyone. Which is why the infrastructure bill and the Build Back Better bill are not somehow separate and distinct from promotion of democracy.

He did that they knew who the unbadged law enforcers were in Portland and Lafayette Square, but I didn't follow up to get the specific answer. It's kind of amazing that that whole subject has dropped from new coverage, don't you think?

Then he tri-folded my question and put it in the inside pocket of his jacket. I was kind of surprised and quite pleased; I guess I had expected he would just hand it back to me.

Then he gave his graceful talk to this very small and highly Jewish crowd, reflecting that Doug and he shared a background in the schmata trade (“schmata” means “rag,” as in, “I like your dress.” “This schmata?”) – Doug's family was Levi-Strauss, Adam's was Farah (at the management level), and one of the great embarrassments of his teenage life was having to wear Farah jeans while all the other kids wore Levi-Strauss. Then he made his pitch that we are under great strain, and that don't worry, the Bipartisan infrastruture bill and the Reconciliation Build Back Better bills would both get passed, and it's important to realize that three really big bills are being passed in Biden's first year and that's totally amazing, and who would have thought that Biden would be so progressive. And as for the midterms and beyond, we just have to get out there and organize and vote, and it's important to realize that this problem will pass, that it's just a phase, and we need to be optimistic because optimism is warranted.

I did get to ask one more question in the open question period – Adam really wanted to get someone else to question, I think, but at first mine was the only hand up – and I asked him, when he had obviously spent so much effort, even under the horrible Trump years, in trying to be accommodating and respectful to the Republicans even as they lied and allowed themselves to be seduced by corruption and moral malignancy, how is he changing his behavior now that he must realize that they cannot be regarded as opponents, but that they are enemies?

He didn't like it when I used the word “enemy.” I was actually using it in a rather technical way – see my post on The Four Freedom's Plus Two that explains why they are so out of the mainstream that they can't be compromised with – but you could see that the word almost made him wince. His answer, though, was interesting. He said that when led the prosecution of the first impeachment before the Senate, he didn't know many of the senators, but that he thought that when he finished there (he didn't gloat about how brilliant his performance had been, really one for the ages), he thought that there were a fair number of Republican senators, maybe most, who didn't think of him anymore as an enemy. But then he went on and in a low key way did say that the Republicans can't be compromised with on the basic issues in question, but would have to be beaten. Which he also said to Kara Swisher:

“And right now as long as the Republican Party is a cult around the former president. They just need to be beaten. The most corrosive thing that Donald Trump did over four years was this relentless attack on the truth.”

“And if you can persuade someone, however falsely, that the other side looks down on you, you will never win over their support. And so I think Donald Trump gave a daily dose of poison into the body politic.”

“And Donald Trump couldn’t do this on his own. He had a lot of enablers. The enablers that I frankly hold most responsible are the men and women I served with in Congress who surrendered everything they cared about, everything they professed to believe in, to uphold this deeply unethical man who was tearing at the fabric of our democracy. So before members of Congress point fingers, we need to do our own introspection. Had leaders in the G.O.P. stood up to Trump instead of so readily capitulated, we would have avoided this.”

So he agrees with the basic point, he just doesn't like the word “enemy.” I think that's a fair point, it really is a toxic word, however accurate, and it has a sense to permanence to it, perhaps, when we know that many of those who are currently enemies are just weak (or bought), and can switch back to being opponents, just as the recent New York Times profile of some of the worst rioters on January 6 indicates that they were reflecting crowd behavior, a weakness of character, rather than just the evil that it seemed to be, and was.

I really wonder if there are plans I'm not aware of to beat back this Trumpist coup – there must be, of course there are. And if there are such plans, it would make sense for the Democratic officials to tell their constituencies, be confident, and concentrate on turnout.

So, I came away little the wiser on Democratic policies, but I did get a sense of Adam the person, and I'm quite sure he is a really good and very smart person. It was great to meet him in person.

But the larger set of questions I had prepared still stand. They are worth thinking and worrying about.

So this guy Adam Schiff is really impressive. Who knows what his future will bring? Speaker, AG, SCOTUS? Whatever, we're lucky to have him there in leadership now. I do worry that he is too much the lawyer and not enough the man directing action, but I have no doubt that, when the need arises, he will meet it.

I'd like to be as optimistic as he says that he is, and it really is hard to think how an entire nation can be so deluded and disillusioned and devoid of true hopes for the future as these awful Trumpists are. How can the worst come to rule? But, the unthinkable has happened before, and what we think we know always has to be approached with humility. How often do we not know what we think we know? In the end we do our best and try our hardest and hope. What else can one do?

But I have to say, I hope the plans of our leaders extend must further than we are given to see. The nice lady I was sitting with at the breakfast, Beth, said she was afraid that the knife the Democrats are bringing to a knife fight is a butter knife. I'd say that's a pretty widely held sentiment.

Budd Shenkin

We Take What Life Gives Us

 

We take what life gives us,

Because we have no choice.

We work with what we have.

We build and we alter and we plan.

We complain and we praise and we give thanks.

We take what we can get.

We deny and we get angry,

We bargain and we get sad,

And in the end we have no choice but to accept.

We take what life gives us,

We really have no choice.

Is it good? Is it bad? Is it fair?

Who knows?

It doesn't matter.

It just is.

Until it isn't.

We live in the memory of others,

And then not even that.

So we might as well laugh.

I mean, what the fuck?

Budd Shenkin

Opponents Or Enemies? Defining Trumpism

 [This is a summary of the longer article which can be found at: https://buddshenkin.blogspot.com/2021/07/americas-six-freedoms-guide-to-our.html]

A major task of politics is to decide if the party you are struggling against is an opponent or an enemy. Opponents agree on basic issues and values; enemies don't. Now that Trumpism appears to have overtaken the Republican party, it is especially important for non-Trumpists to define whether Trumpists are opponents who should be negotiated with and compromised with,  or if the gulf is so wide that seeking to destroy Trumpism is the only viable option.

In 1941, seeking to define the difference between traditional Western civilization and the threatening fascist forces, Franklin Roosevelt enunciated the Four Freedoms as essential to our values: Freedom of Speech, Freedom of Worship, Freedom from Want, and Freedom from Fear. This summary of basic values has endured.

In the 80 years since FDR's speech, two other freedoms have come to be essential to us: Freedom from Discrimination, and Freedom of Fair Elections. That gives us Six Freedoms to tally our scorecard. Does Trumpism agree with these values, or threaten them? This six-fold test finds Trumpian Republicans pretty far outside the bounds of the Six Freedoms:

• Free speech: Trumpist Republicans irresponsibly abuse free speech by using it to foster the Big Lie as a conscious matter of policy, a basic abuse that essentially negates the basic right.

• Freedom of religion: Trumpist Republicans repeatedly press positions that place religious beliefs over civic laws, and Republican-appointed Supreme Court justices increasingly support these positions, with possible reversal of Roe vs. Wade pending.

• Freedom from want: Trumpist Republicans support the new enhanced levels of economic inequality, as particularly evidenced with tax cuts, and continually seek to pare back safety net programs.

• Freedom from fear: Trumpist Republicans obstruct reform of discriminatory policing, support freedom to carry weapons of war, and defend and encourage armed militias who march with torches, assault the Capitol with gallows erected, and chant “they will not replace us.”

• Freedom from discrimination: Trumpist Republicans are strongly anti-civil rights, catering to perceived grievances of whites, often supporting white supremacy.

• Freedom of free and fair elections: Trumpist Republicans have supported Russian interference with elections, support rejection of honest election results, and support voter suppression legislation across the country that even includes legislation and candidates that will serve to disrupt electoral mechanics. 

   

A fair reading of these positions reveals such serious dissent with traditionally held values that it is impossible to present them as positions of opponents rather than positions of enemies.

In fact, a strong case can be made that this outline of beliefs and practices reveals Trumpism to be in its essence a fascist movement.

Budd Shenkin

Ads For Democrats -- The Medium Is Still The Message

So far as I can see, the Democratic party's idea of conveying a message is mired in the past. “Paint a picture in words!”  “I can see it now!  “Let me explain it to you!”  “Major speech is coming!”

Really? In the age of the mini-series? This is what passes for political discourse, explanations of policies? Occasionally whipping out a chart? Give me a break.

Oh, yes, there are the ads, 30 seconds or a minute of high-intensity here's what you need to do? Some of the small candidates here and there do a nice job, I guess working with small agencies. I personally like the Lincoln Project ads, making points with imagination. But otherwise, political ads are nuance-ain't-us.

Here are the Democrats, with policies that are so well thought out, so popular if explained, languishing and taking cover from ignorant potshots which focus on the supposed costs. A simple number makes for good viewing, it seems, according to the media whipping up a story. If the Democrats are calling for a brighter, more imaginative future, why can't they use techniques that illustrate a future, or even a present, instead of a past? If the medium is the message, the Democrats seem to be selling the past. If E. J. Dionne is right, as I think he is, that right now Biden needs to go on offense and say, hey, Republicans, I'm for this, why are you against it, is EJ suggesting, what, a few more speeches?

The thing is, it might be a dated concept, so dated that it was even in Woody Allen's Annie Hall, but the medium is the message. How are you going to present it? If it's the same old way, most of the people are hearing, subliminally, more of the same.

What about this:

Imagine a screen with a right and a left panel. On the left is Infrastructure, on the right is Build Back Better. At the beginning, both are black and white, dull and plodding, in the muck.

“If you pass just the infrastructure bill, which we induced 10 Republican senators to cosponsor, you get (flash the images!)”:

• $110 billion for roads and bridges.

• $66 billion for railroads.

• $65 billion for the power grid.

• $65 billion for broadband.

• $55 billion for water infrastructure.

• $47 billion for cybersecurity and climate change.

• $39 billion for public transit.

• $25 billion for airports.

• $21 billion for the environment. 

• $17 billion for ports.

• $11 billion for safety.

• $8 billion for Western water infrastructure.

• $7.5 bill for electric vehicle charging stations.

• $7.5 billion for electric school buses.

Flash those pictures, quick, on the left screen, in color. The images are the important things. Then say “– or, if you want to have the Republicans in charge, you get … nothing. And the screen goes a dull gray again. We need this, it's our present and our future, we can afford it, and we can't afford not to have it.”

Then you start on the right screen. You introduce it by saying, “infrastructure isn't just things, the real power of America is its people. We need to invest in our people. Here's what Democrats want for our people.” The right screen goes into color, and we see pictures flash by of what it would be, with the text that no one will remember, because what we remember is images, so let's see those images:

• $1.8 trillion for investments in working families, the elderly, and the environment. It includes a tax cut for Americans making less than $400,000 a year, lowering the price of prescription drugs, and ensuring the wealthy and large corporations pay their fair share of taxes.

• $726 billion for universal pre-K for 3- and 4-year-olds, childcare for working families, tuition-free community college, funding for historically black colleges and universities, and an expansion of the Pell Grant for higher education.

• $37 billion to electrify the federal vehicle fleet, electrify and rehab federal buildings, improve cybersecurity infrastructure, reinforce border management, invest in green-materials procurement, and invest in resilience. 

• $135 billion for forest fires prevention, reduce carbon emissions, and drought amelioration.

• $332 billion for public housing, housing affordability, and equity and community land trusts.

• $198 billion for clean energy.

• $67 billion for low-income solar and other climate-friendly technologies.

• $107 billion to establish "lawful permanent status for qualified immigrants."

• $20.5 billion for the Indian Affairs enhancements of Native American health and education.

• $25 billion for small business access to credit, investment, and markets.

• $18 billion to upgrade veterans facilities.

• $83 billion for investments in technology, transportation, research, manufacturing, and economic development. It provides funding for coastal resiliency, healthy oceans investments, including the National Oceans and Coastal Security Fund and the National Science Foundation research and technology directorate.

OK, truthfully, the structure and contents of the Build Back Better programs come from various committees in Congress, each of which put in their own wish list. I don't think I'd put that up in an ad at this time, wait until the paring back occurs. Manchin probably has a point here.

But still the point holds. How are you going to present this, aggressively, making the point, creating visuals in digestible bites, distinguishing yourself and your programs? Are you going to give a speech and bring on some charts, 1980 style? Or are you going to be just a little modern, show that the future is now?

Of course, other steps are necessary to show Democratic dynamism. The inimitable Virginia farmer John Flannery says, go after the insurrectionist criminals, if you don't, you're missing the boat! Totally true. Once again, just think of the images. Is there talk, or is there action?

Anyway, that's my two cents. Dynamism sells, and you can't just talk, you have to show.

Budd Shenkin