Saturday, September 30, 2023

Doctors, Patients, and Hitters

As I think you all know, I believe that there are very few situations in life, if any, that don't lend themselves to elucidation by referring to sports.

Take my current project, where a group of my classmates of the Class of 1967 at Harvard Medical School have started a Humanistic Medicine Initiative, to try to help the current students and trainees develop their knowledge and skill in the caring side of medicine (“caring,” as opposed to the “scientific” side.) Part of this is, how do we help them learn to communicate effectively with patients? I heard that the Kaiser system, which tries to attack every problem systematically, has been teaching a standardized system of communication to its new clinicians. For instance, how long do you wait before you jump into a patient's recitation of his or her story? The usual wait is somewhere under 10 seconds, I think, and Kaiser wants to up that to 40 seconds. Then they have standard ways to start, words to use. Will they succeed in this standardized approach? Maybe so, because maybe the level of current communication is so low there is no where to go but up.

Somewhat akin to that is the recent finding that patients like the empathy of AI better than they like the empathy of real doctors really communicating on their own.

I ran across a more intriguing and sophisticated effort than those, or at least one aiming at a higher level result, in a JAMA article that I put away to save, but which I now (typically) cannot find. I think this was about how to deliver bad news or regret, and how to do it with empathy. As it happens, the author of the article was a resident in medicine doing the learning, and his father was a specialist in medical communications. So the author was going to show his father how he had learned to do it. Piece of cake, he thought – I've been watching my father do this my whole life! I know this gig!

So he does it, he follows all the rules he has learned from watching his father, all the examples he has seen. Then he turns to his father and says, well, how did I do? He naturally expects an A.

Terrible, says the father.

What? Why? I did everything that you do!

That's the problem, says the father, you did me. Now you have to learn to do you.

Crushed, the son has learned that it's not so easy, because we are humans, we are all different, and we all have our own way.

I don't remember how the article went on from there – I'll know when I finally find it – but the point was clear, and it makes intuitive sense. Well done, well written.

So, as I said, there is always a sports analogy to be found. There will always be a way to illuminate the point through sports. I searched my mind, and what came to mind was hitting. There are many great hitters, and they share some characteristics in their swings, but they are all so different! You can watch a swing with the hitter being otherwise unidentifiable – no number or name on the back, no face to recognize -- and some of them you can get immediately right on the nose, and some you can make a good guess at, and there can be such a wild variety of swings, but some you can classify as good, some as bad, so can tell that some of them come from the same hitting coach (does the name Charley Lau ring a bell) and so resemble each other – but I guarantee you, every single one is different.

And it's such a stereotypic task! It's amazing that there is such a variety of approaches! The best hitters share some characteristics -- there are the basics -- and many bad hitters share the same weaknesses, but none are quite the same.  And some will work for some people, and others will work for others, they can learn from each other, there are certain basics, but each one must fit the individuality of the batter.

And, I would add, some work best with some pitchers, and some work best with others. It's a combination. Some patients need one thing, some patients need another, and there are some hitters who can hit some pitchers, and others can hit others, etc., pairs of pitchers and batters that work and some that don't.

And then, think of how many different ways there are of shooting a basketball!

I won't go on, because either I've made my point or I haven't, you accept it now or you don't. Just like some people like what I write and others don't.

But to me, I made my point. Which is that sports is not just pointless games, but in fact, they encapsulate life, one way or another.

Which is a point to rebut my father, long gone now, but still I work to both please and rebut him – Dad, sports are not just a worthless waste of time! Sports are life itself!

Budd Shenkin

Sunday, September 24, 2023

Biden's Age -- Gift Or Burden?


It is a well known but still amazing fact that our President is now 80 years old, and that he is running for a second term and would be 86 at the end of that term. Alarm bells have sounded, many smell disaster ahead. After all, they say, they know what “old men” are like.

But do they, really?  They refer to the stereotype of an “old man” who dodders with frail body, weak memory, decreased reasoning power, depleted energy, inflexible ideas, no capacity to appreciate the new or the young, and liable to be injured or simply collapse at any time. Or, worse, the old man might decline progressively and not leave office, allowing aides to prop him up and take over, or to let the country drift as he himself drifts away, as happened with Woodrow Wilson. Imagine if he should be replaced by a distrusted Vice-President. It's a nightmare scenario.

But think for a moment – does this nightmare scenario ring true with Biden, or is it simply an ageist trope? Here's an alternative: replace the term “old man” with “seasoned leader.” Modern medicine has increased healthy life spans; some say that 80 really can be the new 65. Seasoned leaders resist the impulses of the moment; their hard-won judgement allows them the patience to weigh alternatives and possible consequences, to appreciate ebb and flow, to know which moment to seize, to judge well. Their years have earned them wisdom.

The seasoned leader knows people at home and abroad, who to trust and rely on, and who to be wary of. They know how their chosen field works, because they have been at it a long time. With their perspective, they can actually be more forward looking than younger leaders, and more conscious of their potential legacy. Despite accusations to the contrary, older people tend to relate well to the young. Think of the warm and close ties of doting grandparents as they advocate and indulge their grandchildren, making sure the younger generation has good education and a healthy planet and are fair to one another. In fact, one has to think – wouldn't a grandparent sometimes make a better, more selfless President than a young, ambitious parent? Think “greatness of spirit,” not “old and broken.” Think secure and wise.

As Ronald Reagan put it in 1984, “I will not make age an issue in this campaign. I'm not going to exploit, for political purposes, my opponent's youth and inexperience.... I think it was Seneca but it might have been Cicero who said, if it were not for the elders correcting the mistakes of the young, we would have no state.”

Perhaps it is not President Biden who is stuck in the past, but the critics who cling to out of date stereotypes.



But, to be fair, bad things do sometimes happen to older people. Woodrow Wilson had a devastating stroke at age 63 (old then,) and his wife and aides hid it from the country, while taking the presidential reins in their own hands. Dwight Eisenhower had a serious heart attack at age 65 (old then) from which he recovered in a weakened state. Ronald Reagan may have slipped into Alzheimer's in his 70's (old then) in his second term. Older people are at higher risk for serious illness, although the risk to the young is not insignificant. Think Kennedy. The risks might rise with age, but they are always there.

Since disabilities can occur to anyone at any time, it is important to be able to detect problems early, and to have back up capacities. Recognizing part of the problem after the Kennedy assassination, the 25th Amendment was ratified in 1967, providing a procedure for replacing an ailing President, whether he or she recognize it themselves, or whether it is the decision of the Vice President and a majority of the Cabinet. But beyond that, we have no formal institutional guard rails. Informally, staff and close friends and advisors function as teammates, supporting and supplementing. But for early detection and remediation, more is clearly needed for all Presidents, not just older ones.


Nikki Haley and others have suggested that a presidential candidate 75 years or older should be tested for mental capability to function in the office. Screening for capability to fill one of the world's most important offices might not be a bad idea. We in medicine know that some patients are more at risk of certain conditions than other patients, and we screen for those conditions to ensure early detection and treatment. We know that the concept of “average” can be deceptive – just because you have a higher risk of having a condition doesn't mean you have it. An 80 year old might be healthier than a 60 year old; a 60 year old may demonstrate more mature judgement than an 80 year old. In medicine we don't confuse risk with actuality, we know we have to evaluate the individual.

But here's the problem with Haley's suggestion – it's far too narrow. What conditions could compromise a candidate's performance as President? Surely it's not simply dementia. Other common debilitating conditions are: alcoholism, depression, anxiety, sleep deprivation, delusions, sociopathy, sexual deprivation or perversion, chronic anger. Indeed, a candidate might be quite literally crazy.

What about other conditions that could compromise performance? What about general intelligence? What about work habits? What about honesty? What about ties to foreign powers? What about temperament? What about prejudice? What about the ability to think through problems? What about the ability to build a team, a breadth of knowledge, a tendency to make a country more peaceful rather than more contentious? What about knowledge of government operations? What about executive experience?

These are all serious questions, and most of them are not age-related. That indicates that focusing on Biden's age is really a question of ageism. Yes, being older brings on the risks and characteristics of age, which can cut both ways. But to focus on just “being older” is unreasonable.


So what is to be done? A general health examination including the mental status of candidates would be a good idea, with the results released to the public. Just as the American Bar Association judges Federal judicial candidates as “qualified” or “not qualified,” the American Medical Association could be asked to issue a medical judgement on Presidential candidates. The extent of the medical characterization of the candidate's health would have to be determined. Do we want professionals to issue a judgement on alcohol use, anger management, sleep habits, fitness, paranoia? Or should we leave the status quo alone, with issues known to insiders leaking here and there in the press? Maybe we should leave it at blood test results, the clock drawing test, and short term memory assessment.

In the end, the political system must find its way to judge. In the old days of strong parties and leadership by insiders, the guard rails of protection of the republic were left in those quiet insider hands. Nowadays, when primaries have taken the place of smoky back rooms, more public information is necessary. But beyond that, we cannot now say. We will find our way to how much information is needed as we move step by step.

But for the present, it's best to understand that judging on age pure and simple is foolish. The characteristics associated with age are distributed on a Gaussian curve, and only individual characterizations matter. Claiming that a candidate is “too old” or “too young” or “too fat” or “too female” or “too anything” is not clear thinking. Over 80 and doing a good job vs. under 80 and corrupt and paranoid, you're going to rule out the over 80 as “too old?” Older age and well-tested vs. younger and untested Senator or Governor, choosing the younger on basis solely of age? Does that make any sense? This 81year old, exactly one year older than Joe Biden, says “Hell, no!”

Budd Shenkin

Thanks once again to David Levine for suggestions, including especially the final sentence!

PS – striking recent references:

1. Tom Friedman cites Biden's “wisdom:”

2. Retired Three Star General James Dubik, quoted in Atlantic article on Mark Milley, decries Donald Trump's “cognitive unfitness and moral derangement.” Besides documenting the manifest unfitness of Trump, the article describes the ways in which the executive team and the military were able to erect guardrails through much of Trump's term in office, illustrating how supplementary influence of the organization around the President can be corrective: