Wednesday, January 31, 2024

Budd's Blood Pressure - Fascinating!

Here's a story about my blood pressure.

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

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

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

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

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

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

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

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

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

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



8:15 AM




2:04 PM




10:10 AM




7:20 AM




8:40 AM




9:15 AM




9:30 AM




8:45 AM




8:30 AM




5:25 PM




5:00 PM




5:30 PM




9:00 AM



7:55 AM




7:25 PM




5:35 PM




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

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

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

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

Budd Shenkin

Sunday, January 14, 2024

Democrat, Republican or Independent? Friendly Debate


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

Friend One

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

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


Friend Two

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

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

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


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

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

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

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

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

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

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

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

And that's the way it is.


Friend One

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

Just a few points in reply, please.

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

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

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

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

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


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

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

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

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

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

Dreams are the salvation of life.



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


Budd Shenkin

Saturday, January 6, 2024

Is It Reasonable To Focus On Biden's Age?

Is President Biden too old to be running for a second term?  You might think so – 81 is a big number, with 85 looming 4 years later.  On the other hand, you might be wrong.

As a physician, I’m used to looking at risk factors.  Being old is just a risk factor, just as being heavy is a risk for diabetes, or getting sunburned frequently is a risk for melanoma.  You’re at risk, but you may have it and you may not.  So we see the risk and we test for it.  

What is the risk for being old?  There is a dreadful stereotype of an “old man,” someone who dodders with a frail body, weak memory, depleted energy, compromised reasoning ability, someone who lives in the past and is liable to collapse at any time.  Let’s call that Type 1 — it exists, but it is not inevitable, just because you’re old.

There is also a Type 2 old man, an “old fox.”  He might be a seasoned leader who resists the impulses of the moment, whose patient judgement weighs alternatives and possible consequences, whose experience enables him to make government work, who knows the people and the terrain of the country and the world, whose years have earned him wisdom.  Think “greatness of spirit” rather than “old and broken.” Think secure and clever and wise.  As Ronald Reagan put it in 1984, “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.”  Especially nowadays, in the age of modern medicine, it is increasingly likely that a man of 80 might be this Type 2.

So, just as we observe Biden, is he Type 1 or Type 2?

His stiff walking posture probably betrays some spinal arthritis, which does not interfere with doing the job.  But his health seems excellent otherwise, and there are no reports and no evidence of mental decline.  In fact, his presidency has been the most productive since LBJ, his schedule is more rigorous than George W. Bush’s was, and he travels extensively and meets all over the world.  It’s true that he stumbles over words, but that is nothing new for someone with a history of stuttering.

In short, the evidence we have points to Biden as being Type 2, someone who has grown with age, rather than shrunk.

It’s true, however, that illness can come quickly to an older person.  It is also true, however, that bad things can happen suddenly to younger persons as well — think JFK.  After the Kennedy assassination, Congress passed the 25th Amendment, providing a procedure for replacing an ailing President, whether they recognize it themselves, or whether it is the decision of the Vice President and a majority of the Cabinet. Beyond that, staff and advisors function as teammates, supporting and supplementing when health problems arise.  The procedures to take when a President is ailing are there, even though it can be admittedly difficult to administer them.

In addition, we should also think about this - is it reasonable to center our concern on Biden's age, above other considerations?  Yes, there are risks to age, but think of all the other risks that we have with presidential candidates.  Think of everything that can go wrong when you hire someone.  There is alcoholism, depression, anxiety, sleep deprivation, delusions, sociopathy, corruption, chronic anger. Indeed, a candidate might be quite literally crazy.  There is lack of good intelligence, bad work habits, laziness, dishonesty, lying, ties to foreign powers, prejudice.  What about the ability to think through problems, to build a team?  What about breadth of knowledge, a tendency to make a country more peaceful rather than more contentious, knowledge of government operations, executive experience and ability?

Age is but one factor among many, and to focus on that one factor and to ignore the other risks seems unreasonable.  Biden seems to have evaded the bad consequences of aging and has garnered the positives.  Like a well worn shoe, Biden is a known quantity who has proven reliable and effective, even surprisingly so.  We should judge the man by his abilities and his character and his history and the fact that he is Type 2 older person who has gained wisdom, not one who has withered.

The odds are, Biden will still be driving his Corvette wearing his aviators when the next President is sworn in, in 2028.


Budd Shenkin


Note - a form of this post appeared as an op ed in the San Jose Mercury News on January 11, 2024 -- I thank David Levine for his editorial help, as always.