How To Save Primary Care

Lisa Rosenbaum is a Harvard cardiologist and a wonderful writer for the New England Journal of Medicine. I didn't know her, but she was a student of my classmate Lloyd Axelrod, and I talked with her on the phone maybe a year ago as she was walking around Manhattan. I wanted to know if we were related, since my paternal grandmother's name was Rose Rosenbaum. It turned out that probably not – we were the Philadelphia Rosenbaum's, and Lisa was the Portland Oregon Rosenbaum's. And I told her how great her writing is – true! – and I told her some of the things I'm up to with my class vis-a-vis humanistic care. People in authority must get calls like that all the time, and if they aren't from esteemed professors or someone otherwise distinguished, they shrug it off. C'est la vie.

She wrote a really great article in the New England Journal of Medicine earlier this month. (https://www.nejm.org/doi/full/10.1056/NEJMms2510425). What is primary care worth, and what can we do to save it, and should we save it? She bemoans the need to defend primary care and the personal relationships of all doctors with their patients, and the fact that there are no measures for this.

But she kind of ends it there. What to do?

Well, I have ideas, and I've written them in an article that few will read. But even though I'm pretty sure the NEJM won't accept the letter, I was moved to write it. Because, not to hide my light under a basket, I really do know what needs to be done. And here it is. You won't be able to read it in the NEJM, so you might as well read it here.

Lisa Rosenbaum's observations of the vexatious problems of evaluating primary care, and humanistic medicine (HM) in general, are correct. She knows deeply how important it is, and so do patients. If standard measures and endpoints are not revelatory, it is due to the weakness of the measurements, not the unimportance of relationships. As William Bruce Cameron has famously observed, "Not everything that counts can be counted, and not everything that can be counted counts."ⁱ

Humanistic medicine needs to be treated as a corporate goal, just as much as biomedical excellence and fiscal positivity.ⁱⁱ Clinically experienced and social sciences trained physicians need to be in high positions of authority in the corporations that run health care. Part of their burden will be to develop methods to assess the effectiveness of the organization in this sphere. These might not be exact measures, but as Lord Keynes observed, “It is better to be roughly right than precisely wrong.”ⁱⁱⁱ

iCameron WB. Informal Sociology: A Casual Introduction to Sociological Thinking. Random House, 1963.

iiShenkin BN. Open Notes in the Context of Humanistic Medicine, The Journal of Pediartrics: Clinical Practice 2025; 17: 200155

iiiKeynes JM. Origin obscure.

 

Brutally Frank

 

Brutally Frank

It would be kind of funny if someone were named Frank, and he named his blog “Brutally Frank,” but I'd guess that someone already did. Actually, I just checked and yes, there is a “Brutally-Frank.com,” and it describes itself as “Midwest Psychos Since 2002”, and there is a sketch of a white skull on a black background. There is also a band named “Brutally Frank.” https://www.sonicden.com/brutally-frank/. So I'm not exactly plowing virgin fields here, I guess.

But the phrase just sticks with me. “Let me be brutally frank.” Gird yourself! Here it comes! I've been learning French for the past six or seven years, I've become brutally aware of language, and how idiomatic English is, because I've been trying to learn the way the French express themselves, and naturally it means learning idioms, after learning the basic words and the basic phrases and the basic grammar, although “after learning” is really incorrect for me, because even now as I forge my way brutally forward, I'm still gathering the rudiments of French, and understanding in the process how long it took me to learn all I did about English, and realizing that I have forgotten how much had to be done, year after year, to really master it. It's like erasing all your drafts of a paper and seeing only the final result which you take for granted. So “brutally frank” is one of those idioms that sticks. In the French dictionary all I can find is “brutalement franc;” I'll have to ask Charles, my French teacher, if they use it in French the way we do in English.

“Brutally frank” seems to imply that before becoming that, you were politely less than “brutally frank.” Which means that you were expressing yourself consciously not wanting to hurt someone else's feelings, which we all have to learn to do somewhere along the road to maturity, and which some people then learn to shed in certain occasions, at which time they can declare themselves as being “brutally frank.” In a way, it's like fessing up, I guess. Shedding the acquired skin.

What enables you to be brutally frank can be that all of a sudden you disregard your own safety and say exactly what you think no matter what the consequences, which may be, after all, brutal. Being brutally frank seems to imply pain on the recipient of this truth, but the teller of the truth might be likewise on the receiving end of someone being brutally frank right back. Politeness on one side seems to beg politeness on the other, but that can be thwarted. Politically, most Democrats currently act politely and still expect that the other side will respect the convention of mutual politeness, not realizing that it probably won't be reciprocal. “My friends across the aisle” can well be cooperating in a coup that could be, well, brutal, to be brutally frank about it.

So, here's the question: what leads to our being brutally frank? Or, what retards us from being brutally frank all the time? I suppose would could all be brutally frank whenever we don't fear the consequences, or just because we can't help doing it, or is we don't foresee the consequences. If you say you are about to be “brutally frank,” it's clearly a choice, but if you are “brutally frank” all the time, it might be because it's involuntary. People introduce what they are saying with “to tell you the truth,” but that seems just like a cliché and doesn't imply that a punch is about to be landed. Being “brutally frank” is different.

If you're very rich, you can be brutally frank a whole lot because your money is a cushion. Or you might think so. If you're brutally frank to your intimates, however, the consequences might not depend on money (although it can). Everyone likes to be loved, but some may fear it, or some might despair of it, or some might not understand that being loved also depends on how you treat someone, so even the loss of love might not retard some people from being brutally frank. But if you've got enough money, probably no one can totally hurt you economically – if you've been wise enough not to be over-leveraged – so sometimes the very rich can afford to be brutally frank without even thinking about it. Like a king, maybe; they can, too.

If someone depends on you, or if you have some leverage over someone, and you don't care about the feelings toward you of that person, you can afford to be brutally frank. Fuck them, you might think. But of course then you have to live with yourself for being hurtful by being brutally frank. But of course, some brutes don't understand what this even means, or maybe not just brutes, but those who are feeling-impaired, like some people with autism who can't understand the feelings of others. Probably some people whom we think are brutes are really just autistic and we ascribe brutality to them, because it's not that they want to hurt others or don't mind hurting others, it's just that they can't understand hurting others. But some people are just bastards. There are many reasons that some people are habitually brutally frank.

Or maybe you have tried and tried, you have tried to be humane, you have gone over a matter in tender detail, and you are still not getting through. Then you could well introduce your last attempt to get through with the phrase, “to be brutally frank,” and then talk about the matter as baldly as possible. You don't mean to be brutal, you have taken every possible step not to be brutal, but in the end, there is nothing left. Sometimes, you just can't dance around it.

Then there are those who pretend to be brutally frank, because they think it is charming. They can hurt others by it in the process – he might say in the midst of others, “My dear, to be brutally frank, this outfit you're wearing makes you look like an alley cat,” as he stifles his gloating laugh of derision. (I wonder how you say “alley cat” in French? Would they say that or is it simply an English phrase not found in other languages?) Brutally frank can be intentionally brutal and hurtful. In this case, “brutal” does double duty, to the words and to the act of malice.

A bully can be brutally frank; I guess the man in that example was a bully, if the woman then shrank and shriveled instead of kicking him in the balls, as he deserved. Trump is brutally frank that way – those Somalians are garbage, says the invulnerable sadistic Trump, whose insides must be a true garbage heap. Some people take it for authenticity, as it matches there own inside feelings that they have heretofore had to suppress. Our worst angels is Trump's specialty, to be brutally frank.

All of which brings me to mon sujet (throwing in a little French never hurt, I figure, but to be brutally frank, I'm afraid it's just being self-indulgent.) I have a group of Six Old Guys – an appellation of brutal frankness, I guess, that is not at all the way we feel, but in fact that's the way we would be mostly described by the outside world. We're in our seventies and eighties, all completely with it, at least that's what testing would show. We write emails to our group, a lot on sports, and a lot on politics. We are not monolithic, although no one would be a declared Republican in the group. One of us, the youngest, actually, has moved from Democratic to Independent, he says. Another identifies as liberal, but to my mind would probably qualify as liberal Republican, Javits style, if they still existed. One of us is constantly obsessed with the mindlessness of those who don't recognize the wisdom of Modern Monetary Theory, and decries the destructive conformity of the economic and political powers who retard the progress our country could make without these artificially constructed barriers to utilizing our full potential. One of us is against tribal thought, and for instance, sees Gazan children and Israeli children as equivalent and each worthy of our compassion. All of us support the importance of the existence of Israel, one of us (me) is so condemnatory of the current Israeli regime that he jumps up and down condemning them and distrusts anything that comes out of Israel. One of us is reluctant to criticize anything about Israel and even sometimes uses the words Samaria and Judea. One of us thinks Israel was completely right in handling Gaza (at least, that's what I get from him, I could be wrong), but decries the incipient fascism of Netanyahu. Others vary.

The question is this: in our Six Old Guys group, how much are we brutally honest? How well do we know and trust one another? How much need we respect the grounds of sensitivity of one another – don't tread there! And how and when can and should we be brutally honest? And how much does not being brutally honest degrade the level of our connection with one another?

On Israel, we have to be careful, because it is sacred ground for one of us, and feelings will remain deep. I myself feel betrayed as a Jew by the Israeli regime, and I fear that Israel has lost for us the most precious heritage that being Jewish means. I remember when my mother said to me, as she instructed me about the world, I think as we were walking somewhere in West Philadelphia, “We're Jewish.” What did that mean? It took a while to find out. We weren't religious, we didn't belong to a temple, we were informed by my mother of the various forms of fitting into Judaism and degrees of fitting into the non-Jewish world, and how could you be Jewish and not be either religious or observant? It involved a set of values. And each day those values are violated by the Israeli regime that violates those values on behalf of their own understanding of what I means to be Jewish. But another one of us has said in the past that one of his rabbis has said, Jews should not speak ill of other Jews (I may have that wrong.) Of course, I dispute that, and I think pretty much everyone else of our group does, too.

So what do we do? We have come up with our solution, which is to agree to disagree. We try not to harp on it, we don't ignore it, but we don't press too hard although we admit our feelings. Are we brutally honest? We might be brutally honest about our feelings on the matter, as much as we can be, but we restrain ourselves from criticizing each other. We recognize the humanity of each other, and we tread carefully. We let love of each other triumph over the urge to fight. Instead, we will shift the conversation to other matters on which we disagree, such as the value and substance of Draymond Green on the Warriors. We all admit that he is a basketball genius, but some of him hate him as dirty and cruel, and others love him despite his problems with expressing anger. On that matter, we can be brutally frank, I guess, although we restrain ourselves from going deep into each others psyche as to why we each feel that way.

Likewise with Bari Weiss. Some of us defend her, others feel she is an awful representative of the weaknesses of humanity. We have had to call a moratorium on the discussion into more evidence comes in that my opponents in the discussion realize the errors of their ways.

Actually, to tell the truth, not saying brutally frank, it all started with an argument over Bob Cousy, some of us declaring him an early basketball genius, others declaring him a talented man made into a giant by various people and forces, the worst being Celtics announcer Johnny Most. The disagreement remains, but does not fester, and discussion of basketball greatness has persisted in our group for years. Occasionally the topic of Cousy reappears, but it seems now an early beacon of how our discussions have evolved. In fact, it is now a running joke with recurrent mirthful calling into question the sanity of the other side. We started in controversy.

We distinguish ourselves as persons as distinct from the opinions we hold. We might try to be brutally frank about issues at hand and to make our cases as trenchantly as possible, but we desist when it comes to each of us personally. We maintain a high ideal with each other, to think the best of each other, and brutal frankness has a place only to be brutally frank in bringing to the attention of others of each other's inherent worth, and the inherent worth of us as a group. Let's be brutally frank, we say in effect, to some extent, for better or for worse, we love each other, or at least we value each other, and recognizing that in brutal frankness is worth the risk of being brutally frank. And the best use of being brutally frank is to bolster the other when they underrate themselves.

Wouldn't it be great if one of us were named "Frank."  It seems to me, anyway.

Budd Shenkin