How The World Is Organized -- The Trump Model

 

What is going on with Trump's view of the world? He wants to stop supporting Ukraine, is very iffy on NATO, hasn't said much about Taiwan, but wants to flex on Mexico, Canada, Panama? What's up?

I can't review all the different ways of organizing the world – not my area of expertise – but clearly we have had empires (Rome, China, British), and we have had configurations of independent states with balanced power(Europe after the Council of Vienna). We've had a system of international laws that recognize countries' boundaries and strive not to interfere internally in their affairs (never really respected). We've had a dual-centric world – USSR vs. USA in the Cold War. We've had systems where armed interventions are supposed to be abjured – post WW I. And so on. Some would say the world has always been organized by strict power, and ideas to stop war and rule by recognized rights is most a modern attempt. But as I say, it's not my field.

So, as far as I've been alive, the world has been dominated by the thought that we should have a universally recognized system of laws and avoid wars. At least, that's what I've seen. Now we have challenges to that, as the Chinese seem to say that this so-called system of rights and respect is hypocritical, and just hides the continuation of the long era of Western domination. And now, it seems, we have a new view, probably a view that would be called “realist,” from Trump.

That view seems to be this: We know that Trump has fancied himself a realist of the thuggery of the world. He has idolized gangsters. He thinks it realistic to understand that countries kill people, they just hide it. The states are all hypocritical, Trump thinks, they say one thing and do something else. The words are on the surface, but it's something else beneath.

He liked to hang out at construction sites at his father's buildings. The working class sees power and people being compelled, not cajoled and persuaded. He himself likes to bully. A lot. So, I think he sees the natural order of the world being based on power and ruthlessness. That would mean that strong states bully weak states, especially nearby ones. This leads to a multi-centric world where regional powers dominate their neighborhood. This is an ancient situation, where transportation and communication was none, or months, or years. In those days a regional power would think of themselves as a world power, because their worlds were small. Nowadays, we know better than to think ourselves isolated, but with the threat of nukes keeping world powers at a distance and enforcing limits, no one should really aspire to world domination, but they can aspire to regional domination.

Who is this reminiscent of? Well, that was the world Hitler envisioned. Let the Japanese dominate the East, let the USA dominate the Americas, and let Germany dominate Europe. Hitler couldn't see why others didn't agree. That's also – relevant to Trump – the view of the Mafia. Let one group dominate Buffalo and don't bother them, cooperate when possible. We keep Brooklyn and Queens, let others have New Jersey. We can compete in new areas, like Las Vegas, but we won't threaten the home territories of the other families. And in both these cases, Hitler and the mafia, force is the dominant influence.

So that's the way Trump sees the international organization. That's why he thought Putin's invasion of Ukraine was brilliant. He surely understands Xi's determination to take Taiwan, with Hong Kong already digested. He thinks it's just weak for the US to allow nearby weaker states to be independent – why don't we dominate them the way the USSR dominated Eastern Europe? It's our right, because we're strong. Mutual respect of borders and sovereignty is stupid and weak, to Trump's understanding.

And what do the leaders of these blocs do? They make sure they get themselves rich. Putin is reportedly the richest man in the world. I hear that he has a deal with each oligarch that he, Putin, personally, has a 50% interest in each of their enterprises. That's why Trump idolizes him. Of course! He's the strongest and that's what he deserves. He's due it. That's exactly what Trump thinks he's due. It's the way of the world, the true order, not this made up stuff about mutual respect and ideals. Realism.

So, no mystery. We don't interfere with the way other dominant states rule their area, and we don't care what they do. Human Rights? Gimme a break. That's made up stuff by the Sunday School crowd. Me, I'm a realist, Donald the Realist. He was the strongest in his family and he dominated them, he was the strongest in the Republican field, and now he's the strongest in the country. Don't give me that stuff about right and wrong.

For starters, Donald no doubt wants a 50% personal interest in the Panama Canal, and a 50% interest in each Canadian energy company.

Why not?

Budd Shenkin

Humanistic Care - Defining and Implementing

 
Medicine is supposed to be humane, kind and caring – to be humanistic.  Yet both patients and doctors complain that our current system lacks precisely that quality.  Patients complain that their doctors often don't get to know them well, that when they are sickest they are cared for by strangers in non-patient-centered teams, and that they get lost, neglected, and delayed in a complex system.  Doctors complain about burnout, alienation, even moral injury, as they, too, miss the human connection with patients and regret the systematic obstacles they face.

Two prominent influences for this decline are, ironically, the great advances in Biomedicine (BioM), and the ubiquitous business methods utilized in medical care organizations.  The proliferation of specialists, procedures, and studies has presented organizational challenges, and efforts to achieve systematic efficiency, productivity, and profit have often given short shrift to the necessity of warm human interactions.

The loss of Humanistic Medicine (HM) is not inevitable, but it must be understood if it is to be protected and reintroduced to the system.  First, HM should be defined.  Second, we should examine its composition, to decide if HM is central to the mission of medicine, or if it is only a frill that might as well be neglected.  And third, we should define some necessary steps to implement HM in practice.

Definition

The standard definitions of HM cite the actions of the doctor as the central factor.  One example: “the physician’s attitudes and actions that demonstrate interest in and respect for the patient and that address the patient’s concerns and values. These generally are related to patients’ psychological, social, and spiritual domains.”  Another source cites the “Three C's”: “(HM's) main components(are) 'comprehension' of the patient's narrative and importantly – emotions; leading to 'compassion' and a 'commitment' to act trying to help as much as possible.”

These definitions have two shortcomings.  First, they are process-oriented rather than outcome-oriented.  The desired outcome of HM is that the patient should feel known as a specific individual, not a cog in a wheel or as an input, and should feel cared for and cared about.  Second, even though the definitions do well in describing desirable physician HM actions, they are too narrow, because they ignore the contributions of other personnel, and the system of care itself.

A corollary to the outcome definition is also important: the benefits of HM accrue to the givers of care as well as the recipients.  Humans feel great satisfaction in giving to others.  Doctors, other caregivers, and even system planners and managers benefit from treating patients with high-level HM.  In fact, it can give significant meaning to their lives.

The Content and Extent of HM Services

HM is effected both by the organizational system of care and the individuals within the system.  The system's design and functioning let patients know if their needs come first or last.  For instance, are appointments made easily and timely, or (for instance) is a patient with a new cancer diagnosis made to wait in psychological anguish many weeks for a first appointment?  If it is the latter, that system could be accused of HM malpractice.  Likewise, is the length of an appointment tailored to individual needs, or is every patient wedged into the routine average time of a visit?  Is continuity of care respected, and are various specialists and tests all coordinated in a patient-centered way, is there always someone for the patient to turn to for personal help, or are patients left in the lurch?  These are just examples of the myriad of organizational HM factors.  Organizational leaders, system designers, software designers, human relations departments, managers and others are in charge of all these items of HM.  

All service industries have to accommodate customers, but medicine is a special service business.  No other line of business addresses “customers” so intimately, with such emotionally-laden, high-stakes and sometimes complex and dangerous pathways and decisions.  The pressure on patients and clinicians can be immense, as they deal with life, death, disease, disability, anxiety, and anguish.  Patients and their families need to be cared for with an intimate knowledge of their emotions, backgrounds, and beliefs, as the standard definitions point out.  Patients don't just need a reliable sales representative as with other businesses, they need someone whom they can trust with their most precious possession of life and health, someone with deep understanding and compassion and skill and reliability.  Figure One shows why HM is central to the medical mission, not peripheral.  Any system design or educational effort or practitioner neglecting that special responsibility of caring in medicine is in violation of the medicine's central mission, to cure when possible, but to care always.

Requirements to Implement HM Services

If HM has weakened, which seems to be the consensus, what is needed to strengthen it?  Most importantly, the priority of HM in health care organizations and medical schools should be promoted  to stand beside profit and BioM excellence as an equal top priority.  This takes leadership, but it also demands support in the ranks, most prominently from doctors, other caregivers, and patients, those who experience HM most directly.

Instead of the current lip service, this high priority must lead to sustained attention and devotion of resources.  Managers must be given the task of maximizing HM to the extent possible.  They must learn to implement HM-friendly conditions, developing processes that are more patient-centered and less factory-like.  Electronic communications should be an asset for HM, not an additional barrier.  Measures of HM must be developed, even if they are based on process rather than outcome, so that they can stand beside the current measures of productivity, financial profit and RVUs, both of which notoriously ignore HM, and in fact classify time spent on HM as waste.  Business management techniques are valuable, but the goals of medicine must be recognized as different from typical businesses.

Likewise, medical education must specifically target HM teaching, especially in clinical training, where HM teaching has often been assumed rather than specifically included, and where HM has often met the counterforce of an “informal curriculum” that discounts HM.  BioM is relentlessly taught and tested, appropriately, but HM needs its own emphasis in imaginative ways that suit it, and take it out of the shadows.  Every medical school typically has many HM-friendly personnel; they need to be mobilized into active contributors to a coherent HM effort.

Finally, incentives for practicing strong HM need to be harnessed.  Inherent idealism in students and practicing doctors is considerable, but in addition to idealism, HM productivity and excellence in teachers, practitioners, care teams, and managers needs to be recognized, celebrated, and paid well.  

Conclusion

While it is complex, HM is definable.  While BioM is of ultimate importance in curing, the caring provided by HM is a worthy partner.  Humanistic care is not a frill, it is essential to the medical mission.  

All organizational change is difficult, and strengthening HM will be no different.  But since the basic elements of HM are known, the task is mostly one of reengineering rather than of basic research.  With a readjustment of priorities and with devoted effort, it should be well within our current capabilities to re-humanize medicine.  Where there's a will, there's a way.

 

 

i. Gilsdorf, JR. No one in charge. N Engl J Med 2024;391:974-5.

ii. Dean W, Morris D, Llorca P-M, et al. Moral injury and the global health workforce crisis. N Engl J Med 2024;391:782-5.

iii.     Branch WT, Kern D, Haidet, et al. Teaching the human dimensions of care in clinical settings. JAMA 2001;286;1067-74.

iv.     Schattner A. The essence of humanistic medicine.  QJM: An International Journal of Medicine 2020;113; 3-4.

v. Hundert EM, Hafferty F, Christakis D. Characteristics of the informal curriculum and trainees ethical choices.  Acad Med 1996; 71; 624-42.

	Challenges to Caregivers in Humanistic Medicine
Patient relations
	Doctor-Patient Relationship	Understand choices available, apply which model is appropriate to each situation and patient.
	Role of the doctor	Knowing how to integrate professional demeanor with personal and professional authenticity
	Doctor flexibility	Understanding the history of relational expectations, different national and cultural expectations, and how relationship expectations have changed over time, with patient independence emergent, and paternalism in decline
	Doctor flexibility	Understanding how to adopt different styles for short-term and long-term patient relationships
	Understanding patient needs	Understanding the power of projection, how patients need to feel they are in good hands
	Patient variability	Understanding both the commonality of patients, but the differences that culture and finances and other circumstances present
	Communication	Knowing how to elicit and communicate information and feelings effectively and sensitively
	Emotional distance	Be conscious of what the distance is for each patient and family, know how to be close and available, but still objective, know your own needs and capacities.
	Empathy	Know how to be truly empathetic from one’s own experience and practice, and know how to communicate it.
	Caring for	Be conscious of and know how to fulfill patient need for emotional support, and for continuing positive monitoring of medical progress and offer guidance.
	Boundaries	Understand and adhere to boundaries of patient relations
	Power relationship	Understanding the power relations between doctor and patients, and not using it inappropriately
	Respect	Treating patients with respect, as a patient with disease, not “the thyroid in 208,” not “a fascinoma”
	Navigation of difficulties	Knowing how to handle difficult and provocative patients. Understanding clinician anger when patients don’t fulfill sick role properly.
Severe Disease
	Deliver bad news	Knowing how to and when to give bad news, such as a diagnosis of serious disease, returning cancer, untreatable condition.
	Caring for seriously ill patients	Knowing how not to shy away from very sick people
	Organizing clinicians	Knowing how to integrate into present care physicians and caregivers who have treated the patient in the past, especially PCPs.  Coordinating specialists with consistent voice for patients
	Organizing team care for seriously ill patients	Assigning roles, appreciating all team members, coordinating actions, sharing understanding of actions and goals
	Switching from cure to care only	Knowing when to stop treatment and switch to palliative care, involving and listening to the patient and family, but showing leadership
	Caring for “incurable” patients	Knowing what to do when there is nothing to be done, how to be there with the patient
	Cooperate with family in terminal disease	Knowing how to comfort families of the dying
	Confronting death	Knowing how to process death, the family's feelings and your own - understanding and accepting the natural course of life and death
	Making sense of serious illness	Knowing how to employ narrative medicine to help give share a meaning for the patient’s life
	Making sense of serious illness	Knowing how to adapt to belief systems and values of the patient to put life and death in perspective

 

The Heart of Scientific Progress

It's a little crinkly as a photo, but this is the image of my article, taken from the post a few days ago, as published in the East Bay Times/San Jose Mercury.

 

 

And also the on-line version:

Opinion: The heart of scientific progress beats for all of us

It takes money, time and patience, but constant investment in medical science helps millions of people to thrive

(With permission from David Levine)

An image from a fluoroscopy shows, to the left of center, two blockages in David Levine’s right coronary artery.

By Budd Shenkin

UPDATED: January 9, 2025 at 5:44 AM PST

I’m in my 80s now, so I remember what life was like in the 1940s and 1950s. In those days, heart attacks hung like the Sword of Damocles.

They took the lives of so many, and few knew what to do about it. Several times, neighbors called my dad, a neurosurgeon, to their houses, only for him to find someone dead in bed. At the news of the death of another friend, Joey, who died at age 39, my parents could only shake their heads.

Philanthropist Mary Lasker and U.S. Sen. Lister Hill of Alabama took the long view. Seeing the health problems that beset America but also seeing the beginnings of medical science progress, in 1955 they persuaded the federal government to vastly expand the National Institutes of Health, targeting research on heart disease, cancer and stroke, the major killers of Americans. Over the following decades, the NIH and other agencies have spent billions of dollars on in-house research and on grants to hospital and university researchers. Amazing progress has ensued, benefiting us all.

Here is one personal example. In early December, my next-door neighbor David Levine, a 71-year-old law professor in apparently good health, felt some discomfort in his upper back. He wisely visited his primary care doctor. Suspicious of a heart problem, she sent him to cardiac stress testing.

The stress testing was abnormal, which led to scheduling an angiogram promptly. As David nervously anticipated his angiogram, I reassured that this is now just routine, the welcome medical situation of “another one of these” rather than the dreaded, “Hmm, this is challenging.”

The angiogram would have seemed otherworldly to my parents’ generation. The cardiology team made a small puncture of David’s right radial artery and threaded a catheter up into his coronary arteries. They were surprised to find that the right anterior descending coronary artery was 90% blocked in two adjacent spots, a very dangerous condition.

They inserted stents and transformed the arteries from 90% blocked to 0% blocked in just a few minutes. David was under waking sedation for the 90-minute procedure, answering questions from the surgical team and watching continuous images of his beating heart on a monitor as they operated.

After the procedure, the interventional cardiologist told David he was only a few months from a heart attack — the 1950s scenario. Instead, just four hours later, David was on his way home to resume his family and professional life. We laughed together at the wonder of it all.

David’s story is repeated daily for people in every walk of life. Did Lasker and Hill dare to imagine this future? We must be grateful to them and to the researchers and practitioners who developed such techniques, the professionals who care for us, and to the leaders who continually invested on behalf of subsequent generations.

Was it too expensive? We can ponder government spending priorities, but as Lasker said, “If you think research is expensive, try disease.” It takes money, time and patience, but look at the results for millions of people.

With a new presidential administration assuming power in Washington, we hope that they honor the vision of Lasker and Hill and keep investing in scientific progress. Let them not be seduced by the vision of headlines trumpeting mindless “efficiency” and claims of “money saved.”

Let’s hope we won’t be led by those who know the price of everything and the value of nothing. What could be of higher value, after all, than what we have just experienced?

Dr. Budd Shenkin is a physician in the East Bay and a graduate of the Goldman School of Public Policy at UC Berkeley, where he is a member of the board of advisers.

Life And Care Of Heart Disease - A Little Perspective

 

 

                                                       David Levine - today

 

Here's how things have changed.

I was born in 1941, the eldest of four. So I remember the late 1940's somewhat, and the 1950's very well. In those days people married and had kids earlier than now. My Dad was born in 1915, my Mom in 1917, so they were parents at ages 26 and 24, and parents of four at ages 34 and 32. So I remember things they said probably by the time I was 10, and they were like 36 and 34.

Although the modern medical era had been born before I was, medicine wasn't very advanced compared to now. The invention/discovery of penicillin was an early sign of miracles to come when I was a kid. We were down the shore in Beach Haven, NJ, for the summer – my Mom took care of us kids and my Dad came down on weekends I stepped on some glass, probably, in Little Egg Harbor Bay and cut my foot, although I was convinced that a crab had bitten me. We got it sewed up by a local doctor. Was that the time it got infected, or was that from some other accident? I don't know. But whichever time it was, I got a suppurating infection of my foot.

In former days, that infection could have been catastrophic. But now we lived in the penicillin era. I was taken back to Philadelphia, I'm pretty sure it was to the Graduate Hospital where my Dad, a neurosurgeon, often had patients, and I was treated with penicillin. Those weren't the days when they gave you pills, or when you got your intravenous meds by IV's, and it wasn't even the time when you got spaced out doses of penicillin with lidocaine that lasted 12 hours or more. Nope, it was the era of four doses a day by intramuscular injection, and it hurt like hell, as I remember it. My Mom left the other kids at Beach Haven, under the care of whom I don't know, and stayed with me for the few days it took for the infection to be cured. All this, for a foot infection of a wound.

The shots hurt, so when the nurse showed up, I cried and protested. Then my mother got herself together and talked to me quietly and convincingly, and said I'd have to take the shots anyway no matter what I did, so why didn't I try to be brave and not protest? The next time the nurse came in I smiled a big false smile and turned over on my belly to get my shot in the ass. The nurse said, “What's got into him?” She gave me the shot and I absorbed the pain quietly. Amazing what my mom could do when she put her mind to it.

But what modern medicine hadn't gotten around to yet was heart disease. There was a lot of smoking, and who knew about cholesterol? I remember my parents saying, when something came up about heart attacks, I guess, “Remember Joe Ziggerman?” And they shook their heads. I asked what happened to him and they said that he “dropped dead” of a heart attack at age 39. “39,” they said. 39.

We lived at a house in West Philly until I was in 8^th grade, in a semi-detached house, 422 South 47^th Street, just down from the corner of 47^th and Osage. Our front door opened onto a little landing that we shared with the house next to ours, where the Barkan's lived. Ben Barkan was a red-headed lawyer of Democratic persuasion, and they had two kids I remember, it might have been three. Ben was a well-built man, his wife Sylvia was an open-hearted and expressive woman with dark hair who hated Republicans. It was the McCarthy era, and tensions were high. I think they were ADA members, Americans for Democratic Action. Ben was also a tennis player, although we never played with them. It must have been after we moved to Wynnewood in Lower Merion Township in the suburbs when I heard that Ben had died while serving in a tennis game, dropped dead of a heart attack. I remember one dinner party at my parents' house in Wynnewood, I'm pretty sure it was when I was home from my freshman year at Harvard, and my parents had invited Sylvia, who was there alone, a widow.

Just over a block away, at 46^th and Osage, lived our close friends, the Levins. Father and mother were Herb – another liberal lawyer, although one more practical than Ben – and Beck (Rebecca) and their three children, Bob and Susie and Larry. I don't know when it was that Herb had his heart attack, but I know it was after Susie had died of leukemia, which would have been fairly readily treated if she had had it today, because treating childhood leukemia is one of the great achievements of modern medicine. When Herb had his attack they called my Dad and he took Herb down to Penn, not too far away, and Dad protected him from the residents as best he could in the ER. Dad said that the resident kept yelling at Herb, “What's your name?” Dad said, “I'll tell you his name, just treat him.” Of course they didn't have much to treat him with then, maybe give him some oxygen. But thank God he survived. Still, that's what lurked in those days.

When we moved out to Wynnewood, we lived in a new subdivision of what had been a rather large estate a block down from Montgomery Avenue and North Wynnewood Avenue. (Wynnewood, I remember from the plaques, “Named for Thomas Wynne, physician to William Penn, and first Speaker of the First Pennsylvania Assembly.” At least that's how I remember it.) Our little subdivision had Jews, all Jews, in the WASPy Main Line that had already seen Jews in Merion, but now had come to Wynnewood. I remember sitting with my parents in the real estate office as they were buying our house, the Jewish developer telling Mom and Dad the names of the other families who had moved in – Herb Lipshutz, the plastic surgeon, the Simon's, the Lowe's, the London's, others. The real estate agent who was handling all the sales commented, “Where are the O'Connor's and the Kelly's?” The developer and buyers turned their heads toward him and acknowledged the comment with polite and tentative laughter. Neighborhoods change, it can seem like an invasion, I guess, but for real estate agents, it's just business.

So we moved in and Mom and Dad stopped paying four tuitions to Friends' Central School and sent us to the very good public schools of Lower Merion. We made friends with our neighbors. One night my Dad got a call from our next door neighbors, the Simon's, and Dad went and found the father of the family dead in his bed from a heart attack. I was gone to college at the time. Somewhat later they got a call at night and Ed London was dead in his bed as well.

In the 1950's the NIH was formed, on the initiative of Mary Lasker and Democratic Senator Lister Hill of Alabama – a monumental achievement of lobbying a government to do the right thing. In the coming decades, national health policy targeted heart disease, cancer, and stroke as the big killers. Billions of dollars went into direct governmental expenditures and grants to university researchers. We are now 60 or 70 years out from that beginning. It is the grandchildren of the generation that started the effort who are benefitting. They say that democratic governments can't stick to something, and that government is ineffective. There are those of us who differ with this diagnosis.

It's true that our national expenditures for health care underemphasize primary care and overemphasize specialty care. But it isn't true that we are getting nothing for our money. Herb's son Bob, my close friend, had severe heart attacks ten years ago, received heroic care including several days of hypothermia, and is alive and very well today. If he had suffered from his heart disease at the time of his father's illness, he would not be alive and well today. The progress has been immense. See his great book, I Will Keep You Alive, available from author.

Then there is what happened this week. On Sunday, my next door neighbor for over thirty years, David Levine, law professor at UC College of Law in San Francisco, came over to show me the documents from his cardiac stress test. He had had some discomfort at the beginning of December and had made the good decision to see his new primary care doctor. She was suspicious of something being quite right with his heart and ordered cardiac stress testing. The stress test revealed an abnormality with the S-T segment of the EKG and she ordered a cardiac angiogram to be performed the following Thursday. I looked at the report and explained some of the terms and findings with David. Doctor's don't have the time and the relationships with patients to do an adequate job with explaining, and it takes repetition anyway, so having a doctor friend next door is a good thing. My Dad always said, each generation of a family should have a doctor, to protect the family from all the crap that can go on medically.

I reassured David that what they were going to do was not dangerous, and in fact was to be welcomed. He was nervous and I told him that of course he will be nervous, but that I wasn't, because it would be routine. What we always want to be is “another one of that;” never “something interesting.” Yesterday he took Lyft to be at the hospital at 5 AM to be the first case of the day. At 7:45 AM I took his wife Joanna out to the hospital to sit and wait for him; another friend came a couple of hours later to sit with her and to take him home after I left. The procedure found a right anterior descending coronary artery 90% blocked in two adjacent spots, and the interventional cardiologist inserted stents that took the arteries from 90% blocked to 0% blocked. He told David that he was surprised to find the arteries so compromised, and the odds were that within a couple of months David would have had a heart attack. David was given waking sedation for the 90 minute procedure and could watch the image of the operation on a monitor if he craned his neck. It was all done through a small incision in his right wrist that took the catheter up the radial artery to the heart. David was just here today, just over 24 hours after the procedure, to tell me about it.

Ladies and gentlemen, this is Star Trek medicine. Who'd a thunk it? How is this possible? From premature deaths with little or no warning, to early detection and preventive procedures and a smiling man with no residua who will be fine.

In the midst of valid medical discontent, it's helpful to have some perspective.

 

Budd Shenkin