Second Opinions

Paul Levy has another interesting post on the value of second opinions.  He says:

Simon Schurr at Collaborative Medical Technology Corporation suggests in this blog post that current levels of overtreatment and inappropriate care could be reduced by more widespread and judicious use of second opinions.  He points to unnecessary surgeries, overtreatment of back pain, mistreating ovarian cancer, and outdated procedures.

His diagnosis: "The causes of inappropriate care are complex, but often the root is simply lack of knowledge, an honest mistake, or a healthcare provider who simply wants to help a patient when treatment isn’t working. Sometimes, profit-driven decision-making or fear of malpractice claims lead to over-testing and overtreatment."

His solution:  "The best approach may be a combination of well-informed patients asking the right questions and seeking top doctors who stay abreast of the latest research, and rigor in using second opinions."


My response:

Here, here!

Years ago I advocated (in the first ever Sounding Board section in the NEJM) for patient access to medical records, partly reasoning that if medical records got a wider circulation, their quality would improve, because clinicians would know that what they wrote could be seen by others.  Now, EMR serves the same purpose, as does the growth of group practices generally, where you know that your colleagues will sometimes see your patients and read your notes and judge.

Likewise, it's possible that even the knowledge that your patient would likely be seeking a second opinion would be very bracing.  When our pediatric practice seemed to have an excessive number of referrals to specialists for one HMO. I announced that I would be reviewing all referral requests from our group before they went out.  Instantly, the number of requests dropped, just from the knowledge that they would be reviewed.  I then had to send back the referral request for reconsideration by the clinician only rarely; just the existence of the review process did the job -- as expected.

Moreover, if you consider Groopman's How Doctors Think, you immediately are impressed with the desirability of second opinions,  to avoid the cognitive error of anchoring, if nothing else.

Here's another example.  A doctor friend of mine had a father-in-law, I think it was, who was sick for years and years without a diagnosis.  By chance, my friend and his father-in-law were walking around the halls of Dartmouth Medical Center and a doctor friend of my friend saw them, walked up to them, and said to the father-in-law, "You have hemochromatosis!"  He could just tell by the look.  After years without a diagnosis.  A single doctor just can't know everything.

Or, consider this.  Just two days ago I was at our health club and a 76 year old friend came up to me.  He had pneumonia almost a year ago and has never really recovered, he thinks.  For the last few weeks he has felt really, really tired.  He's worried -- as he should be.  He asked me about a second opinion -- from an internist, he specified -- because his regular doctor (who is in fact an internist), who he likes, hasn't pinned down anything.  Is his doctor saying subconsciously to himself that my friend Arthur has just run out his string?  Is he out of ideas?  What?  I don't know.  But I urged Arther to in fact get a set of fresh eyes on him -- take up the case from the beginning!  Why not?  Visits are cheap.

Finally, while we have many specialists in many fields, what we really don't have is a super specialist in internal medicine.  When I did my medical school internal medicine rotation at the Beth Israel we had an attending who was revered for his differential diagnosis acumen (Manny something).  His visits were prized, as various residents sought help, and to stump him.  The Chief Residents sought to emulate him.  But what happened to these Chief Residents when they moved on out of training?  Chief Residency was the best training possible for a job that didn't, and doesn't, exist.  You either go to a recognized specialty, or you go into primary care, which really presents a different set of circumstances than Chief Residency.  (For one thing, primary care puts a premium on prevention, which internists generally do not excel at, nor are they well trained for, etc.)

What we need is an institutional setting for the master internist, someone to turn to, or a set of doctors to turn to, who are really smart.  They wouldn't have to give primary care, and their field would feature breadth, rather than the depth of the recognized specialties.  These would be great for second opinions.

I guess you could do the same thing for surgery, but that's a more complicated issue.

And to reiterate: visits are cheap - it's the procedures that are expensive.

Budd Shenkin

Monopoly and Medical Care

In every industry as a firm gets larger and conglomerates, it explains to regulators that its size will redound to the benefit of consumers, as they will be able to offer new services, etc.  Usually, it is bull-diggy.  Who wouldn't want a monopoly?

Paul Levy writes a very interesting blog called "Not Running a Hospital."  It used to be called "Running a Hospital" when he was CEO of Beth Israel Deaconess, a Harvard hospital, and he renamed it when he left his job.  Before I discovered this blog, I had heard of him from some Teaching Company tapes on Leadership - how he came into a dysfunctional Board at the Beth Israel and laid down the rules and turned the institution around.

Anyway, here is his latest blog and my response:

Self-dealing between a health system and its insurance company

Posted: 13 Sep 2013 06:22 AM PDT

Just when you think you've seen the limits of market power, creativity emerges.  Julie Donnelly at the Boston Business Journal reports:

Partners HealthCare aims to drive new members to its newly acquired health insurer, Neighborhood Health Plan, by cutting off access to some doctors within new health plans offered under ObamaCare.

Neighborhood Health Plan is one of 10 insurers that has been certified to offer subsidized and un-subsidized ObamaCare plans through the state’s Health Connector.

But what Neighborhood Health Plan has is exclusive access to primary-care doctors at Brigham and Women’s Hospital and Massachusetts General Hospital.

Now that Partners, the parent organization of the Brigham and Mass General, owns a piece of the insurance pie, they have decided to offer access to their primary care doctors only to those members who choose Neighborhood Health Plan.

This is likely to drive new business to Neighborhood Health Plan from Boston-area patients who want to keep or begin a relationship with a primary-care doctor at one of the two most prestigious hospitals in the state.
 
This is a departure from Partners’ strategy in the past. Before its purchase of Neighborhood Health Plan, Partners’ offered access to its doctors to all of the health plans within the state-subsidized health plans that were launched under Massachusetts' own statewide health reform.

And I wrote in rsponse:

Paul, this new thrust by Partners' seems really important. 

I get how pissed off you are at them, probably buttressed by a holier-than-thou sanctimonious and hypocritical attitude -- I was at HMS, so I get that.  

But I'm wondering how this fits in with Kaiser?  And maybe Apple -- closed networks, both. And ACO's.  All talk about the importance of integration - the Oliver Williamson (Nobel Prize, economics) idea that incorporating functions within one company can be more efficient than a market.  Don't get me wrong, I'm with you in smelling monopoly, and as a former primary care doctor with an independent company, I never wanted to be incorporated and thus controlled by an exclusive relationship with a single payer.  I thought it was better for patients, and better for our practice, for us to be independent and have multiple avenues of ingress for patients.  And I had no question that an exclusive relationship would spell decreased payments for us in primary care.

But the ultimate problem with our current medical care system is hospitals and hospital costs.  Kaiser cuts them down because everyone there benefits from decreased hospital costs.  Although they are unionized, and that's a problem.  (Interestingly, when you go into an exam room, the medical assistant is wearing a large, prominent pin that says SEIU!!)  So one could say that to get control of the system they need a completely integrated company.  In this case, of course, one could say that it is not a small upstart company competing with the behemoths, but the latter solidifying their position.  In that case, we rely on government and anti-trust, but we know that's not going to work at this stage of the game. 

Anyway, I would encourage you to keep writing about this, as deep as possible.

Budd Shenkin

Obama and Putin - Let's Be Optimists!

So, Obama has waged a “feckless” (my word) and confused foreign policy, Putin has “bested him,” and the US looks inward, the world has no cop, the Russians are back in play in the Middle East where they have been aching to arrive again as a Big Power, they say.

As my roommate Peter Kelley from Aroostook County, Maine, used to say, “Bull-diggy.”  Instead, it is time for optimism.

Let’s get away from American “primacy.”  We’re big, we’re powerful – but we’re not the only ones in the world.  We are a settled country, where the government has a monopoly on violence, which is what a non-failed state is.  OK.  We think we have the best government there has ever been – OK, that’s defensible, although not airtight, and as far as I know, it’s true.  Putin is ridiculous when he talks about democracy, and about everyone’s not having achieved it fully, implying that he and Russia have, I guess, although that’s not certain from his editorial.

The Russian government wanted to come over and lobby the House of Representatives!!  How hard to believe is that??  Why isn’t anyone saying anything about that, I wonder?  Putin publishes in the New York Times – lots of holes in his argument, but still!

The fact is, and has long been, that settled governments have a lot of common interests, overwhelming common interests, against disruptive forces like terrorism (did Putin chuckle an “I told you so” when the Chechens hit Boston?), and against their combined assault on the commons of the earth’s environment.

We have to pay attention to human rights, OK – but it’s better than it used to be.  Jews can still emigrate, can’t they?  China has lifted tens of millions out of poverty.  But still – we have a lot in common, and if we don’t get all absolutist on the human rights thing, the civil liberties (which I treasure), if we concentrate on a more public health point of view, a collective good point of view, we can celebrate a coming together, ice-flow breaking up of American-Russian cooperation.

I get pissed off at Obama, true.  But along with millions of others I got pissed off at Nixon, but in retrospect, policy-wise, he was very good in so many ways.  He relied on Pat Moynihan domestically, and although he was terrible on Chile – thanks, Henry – if he had just had a different personality, he would have been pretty good overall.  And my being pissed off at Obama isn’t even near the ballpark of being pissed off at Nixon, not even at the hotdog stand outside the stadium, or even paying off some kid to watch my car when I’m a few blocks away at the game, not near.  So, let’s just call it a general disappointment that will fade with time and with appreciation of the real achievements of the Obama Administration (excepting Eric Holder and his outlawing of investigative journalism when it concerns the Feds.)  But that’s just personal, not business.

Why not let Putin into the game and work together?  It’s not like we’re doing so great on our own.  Why not let him keep Syria in his pocket (do we really have much of a choice, really?)  Does it really hurt us?  What’s Putin’s position on Israel?  I don’t think he’s against it; I bet he is willing to see a successful so-called Peace Process.  Does he want to construct a new Warsaw Pact in the Middle East?  Don’t think so.  Does he want Iran to have the Bomb?  Don’t think so.  Does he want countries to adopt a Communist form or government?  Don’t think so.  I mean really, even if Russians are mean sons of bitches, where is the threat?  Am I just so blind?  Will the Russians construct a new operating system and outlaw Microsoft?  Will they overtake Google?  Where is the competition?  Oil?  Oil?  We’re all on our way to conservation and home-brewing from shale.  Maybe I’m blind.

So, I’ve thought from the start that Kerry will go down as a remarkable Secretary of State, far surpassing Hillary, who really was a competent presence, but nothing remarkable.  Smart, but not innovative, nor probably very flexible.  Could it still be Kerry for President?  I think that ship has sailed and hit the rocks.  But, could it be a new era, and a Nobel?  Could be.

I’m going far, far into euphoric optimism here, buying a stock as it emerges shakily from a very long base.  It’s really too early to tell.  That’s why this essay will simply stay on the blog, not read by many, and if it really becomes true bulldiggy, who will remember?

But I say, let them work together.  Let’s not forget that Fox News and the war-mongers of the Right, always there, will yell and scream.  David Talbot thinks that it was Kennedy’s opposition to the war-mongers that got him killed (Brothers, 2007, Free Press).  Eisenhower identified the Military-Industrial Complex, and it was only in late drafts of the speech that he amended that term from his initial one, “Military-Industrial-Congressional Complex.”  So, we will hear a lot from the House, whose members’ districts still thrive on the military, dispersed strategically throughout the US.  There are interests, there are viewpoints, there is violence always as a threat.  Personally, I would double Obama’s security detail.

But I’m optimistic.

Budd Shenkin

Syria, Intervention, America's Role

I am no fan of Obama, although I voted for him twice; each time, there was essentially no competition, as indeed there hasn’t been for my whole adult life, in which I have never voted Republican for President.  Just the Supreme Court could tip the scales, but in truth the scales were already way over to the left to begin with.  So, like so many of us, I can vote consistently and be consistently rather lukewarm.

But that said, I think Obama is doing pretty much the right thing right now on Syria.  Whether he has done the right thing up to now, I’m not sure, since he seems to have painted himself into a corner with his Red Line statements.  But even that might be OK.  To give a preview of my analysis, I think it might be more important what Obama and the Americans say, rather than what they do.

Two Roles

First of all, let’s distinguish two roles: fighting on the side of the rebels (Role 1), and enforcing the moral and international legal norm of not using chemical weapons (Role 2). 

The first issue has been debated for two years, and is complicated by our history of terribly mistaken enmeshing wars in Iraq and Afganistan, by the history of the Middle East and our escalating unpopularity there; and by the lack of cohesion of a rebel side, well known religious extremist growing preponderance therein, and the lack of democratic sensibility in the region as made clear by the Arab Spring and its lack of democratic flowers.  As a result of all this and more, the Americans have decided to stay out, citing especially the Law of Unintended Consequences and the lack of immediate American security interests.

The second issue has come up in the Syrian conflict once before under obfuscatory circumstances, but now in the last few weeks much more directly and unavoidably.  There is an international treaty, to which I think Syria is not a signatory, against the use of chemical weapons.  Even if not a signatory, the internationally recognized norm is that such weapons should not be used.  War brings out strange quasi-religious beliefs, it seems, that one kind of death is unlike another – fire bombing of some German cities, Dresden for one, caused much more destruction and loss of life than Hiroshima and Nagasaki, but nuclear bombs are verboten and conventional bombing isn’t.  It’s OK to kill one kind of human – combatants – but not another – non-combatants.  Go figure.

Nonetheless, if there is such a norm, how is it to be enforced?  Who shall enforce it?  Is there really such a thing as a world-wide consensus?  If so, is it represented in the United Nations, or some other supra-national organization?  Or can one nation, the United States, claim moral infallibility and be the enforcer?

I said that it might be most important what America says, rather than what it does.  Distinguishing these two roles is what I meant.  Do we enter the arena at all, and if we do, is it to finally engage in the former conflict as combatants, or is it in the role of enforcer of the international norm?

The Tragedy of American Unexceptionalism

Given the decline of hopes for first the League of Nations and then the UN, some in the “free world” hoped that America would lead.  There was at least some surface validity, it seemed, to American exceptionalism, that we were outside the stark geopolitical arena of interests, that we had a sense of human rights and the just society that we would support anywhere as friends of the court.  Make the world safe for democracy.  The socialists had a competing view but as time went on Stalin did his bit to destroy that myth as geopolitical nationalism became the obvious goal, and as the Soviet Union as a just (and efficient) society became an untenable concept, even to Susan Sontag (far into the Brezhnev era, as I recall – but I digress into a personal bête noir.) 

America was given a pass on its claims for a while, despite United Fruit and the oil companies and the Negro Problem, probably because people could come here from throughout the world and be accepted and do well, and it just seemed like a good place to live and grow up.  After the depredations of the Dulles brothers, Vietnam accelerated the decline of that view of America, and the Iraq deception and Abu Ghraib and other torture and Guantanamo and now unfettered NSA snooping have put the cap on it.  There is no longer any moral high ground left for America in the world’s view.

America is the world’s only military superpower.  People have said, don’t underestimate the evil in the world (true), and how much worse it would be if America were not the world’s cop.  No doubt true.  The problem is, how are you the world’s cop if you have lost the legitimacy you once had?  America could once assemble a powerful coalition of the willing – see Iraq I.  The neoconservatives put the end to that with chimerical coalitions in Iraq and Afganistan.  It appears with Syria all we’re left with is France, the original colonial power there.  Not enough.

Making the Distinction

So, we don’t wade into Syria in the first instance.  Eventually, after what should be called war crime after war crime, the Assad regime uses chemical weapons.  There is skepticism on the evidence, fueled by blowback from Bush-Cheney deception, much of which will not be made public because it rests on surveillance that even Snowden appears not to have revealed, but which I expect to be compelling very soon, nonetheless.  How do you believably declare that you are going to intervene in Role 2 (referee), and not in Role 1 (combatant)?  How can you intervene in Role 2, but not have an effect on Role 1 – that is, how can you penalize the Syrian government for a low blow but not tilt the outcome of the match?

The answer is, you can say what your motivations are, but you can’t fulfill only Role 2 without weighing in on Role 1 as well.  A boxing referee awards points to the opponents for a low blow, which tilts the outcome.  If there is more than a low blow – the boxing equivalent of use of nuclear weapons, perhaps doping the opponent – then the match is declared over and the winner anointed.  If Assad used a nuke the world would be obligated to step in militarily with whatever we had.  With chemical weapons first instance, award points.

This is where I think rhetoric makes the difference, and is the most important thing.  Why are we going in and awarding points?  As the referee.  What kind of points?  Bombing the remaining functioning airfields to hamper the Iranian and Russian resupplies.  Does it help the rebels?  Yes.  Is it decisive?  No.

It would be nice if we could just declare Bashar a war criminal and turn him over to The Hague.  Unfortunately, that is what we have tried to do with Omar al Bashir of Sudan, and look what effect that has had?  As I understand it, mostly a travel ban.  That’s not enough points to award; ask South Sudan.  So, intervention it is for Bashar.

The Usefulness of Consulting Congress

Open discussion and joint decision making is derided by the world that is not used to democracy – interestingly, that derision of “weakness” tells us a lot of what we need to know about the ease of introducing democracy to the world without a parliamentary tradition.  But it will be best for us to do so; it is in our national interest.

The discussion will inevitably give a very complicated but descriptive narration to our motivation.  McCain and Graham want us to fulfill Role 1.  Others want us to fulfill Role 0.  It will be up to Obama to give voice to, and the Congress as a whole to endorse, Role 2.  Maybe it can be done, maybe it can’t.  Maybe it will help others in the world to join us, maybe it won’t.  Maybe it will disappoint everyone from the Saudi’s to the Scandinavians (where are they, by the way, those arbiters of decency?).  But at least it will be us.  This is the way we ought to do things.  If Congress fails, so be it.  That will lead to further discussion and evolution of our institutions.  We need to clarify where we are and how we function, and this whole process should further that need.

Geopolitical Effects

It seems everyone wants us in there for their own purposes.  Assad probably wants us in there so he can rally support of the anti-Americans; ditto the Iranians and Russians.  Even if the declared purpose of America is as referee, few in the non-Western world will see it that way.  But at some point you just have to say, WTF.  Look and learn.

The Israeli’s are probably disappointed; they, too, want a dictator on their side.  The Egyptian military wants us to keep out; they fear the anti-Americanism that will result, and the al Queda predominance of the rebel forces.  The rebels want us in, they want the points.  I bet the Russians want us out, because it will be hard for them to profit from our entry, and they want to keep Assad on their side – “human rights” and “Russia” cannot be uttered believably in the same sentence.  The Chinese probably want us bogged down and they benefit from Anti-Americanism as they buy up African land.  No one wishes an empire well, it seems – what did we bring the world except prosperity and human rights?  (I exaggerate, but can’t help myself from echoing the great scene in Life of Brian as the opposition sects decry the effect of Pax Romana.)

But to all of this, I think you just have to say to the rest of the world, deal with it.  We’re awarding the rebels points, whoever they are.  If it becomes clear in the future that we can really make a credible contribution to peace, prosperity, and human rights in Syria, we will.  But for right now, we’re just awarding points. 

Budd Shenkin

Control is not a four letter word

I read that Jeff Bezos, the Amazon founder-president who bought the Washington Post, according to an anonymous colleague “makes an ordinary control freak look like a stoned out hippie.”  It sounds a lot like what they said about Steve Jobs. 

Despite their success, you can sense the irritation in the accusations.  So given their success, you have to wonder, is control a bad thing?  Seems to me you have to distinguish: is it control so you are in control for your own reasons, or is it control for the sake of the product or service being produced?

Type I Control Freak (CF1)

The usual “control freak” in a company – or in a family for that matter – is someone who likes to be in control for his or her personal reasons.  Sometimes it is a way to treat anxiety – if you are in control, someone else isn’t, and you won’t be hurt.  Or it could also be someone who is afraid of being fired.  For instance, if she hoards information and divides up tasks so that she is the only one who can operate the unit, who is thus indispensable, firing is made much more difficult.  This is CF1a.

Alternatively, forget weakness.  Some people hoard information to maximize their own prerogatives.  They take vacations when they want and let others work with the left-overs, and so on.  In short, they enhance their own power and use it for their own gain.

Type II Control Freak (CF2)

On the other hand, what about someone who is really smart, or really well-trained?  Or someone who will not make compromises with quality?  Or someone who will work as hard as possible to get things right?  Should they be sharing control (and power) with the less smart, the less trained, the less hard-working, the more likely to compromise quality?  What would you rather own, a true Giovanni Bellini, or one From the School of Giovanni Bellini?  Needing control can be not for the sake of personal power, but for the sake of getting it right.

Not to put myself in the class of Jobs and Bezos, but I was head and sole owner of a medical group.  When it came to business and medical organizations, I knew more than the constituent doctors by far: I had studied it, I continued to study it, and I continued to experience it day after day.  I made so many mistakes that I eventually learned from that no one could match me in mistakes made and lessons taught!  I had been there.

Moreover, as the owner, I had a perspective that was different from others.  I was responsible for the final product, and would have to take pride or shame from that product.  I stood to lose or make money on performance.  Growth that came from smart moves and ability to please patients and referring physicians would accrue to the group’s benefit, and to mine, and less directly to each individual clinician.  So my idea of control was grounded more on CF2, not CF1.

As an example: this may or may not be true, but I recently heard that since I sold my group one of my initiatives was proving successful.  I thought that increased patient accessibility was important, so instead of having “secret” Sunday office hours, we would publicize our availability on Sunday to patients, make the hours regular and fully staffed.  The result would be both improved patient service and improved competitive advantage for our group in attracting patients.  So, what I heard was that the Sunday hours were proving so successful that the clinicians were complaining that they were working far longer on Sundays than they were accustomed to.

If I were still in control, I would point to this as a sign of success.  Yes, it is more burdensome for clinicians, but in an area of high competition, this could prove the difference between failure vs. survival.  It could lead to actual practice expansion in a difficult locale.  But what I heard was that there was now consideration of how to curtail availability so the staff and clinicians could get out earlier.  The leadership intended to let that happen; no rocking the boat.  If I had insisted we find a way to keep the advantage and find a way either to compensate clinicians for the extra work or hire someone else, etc., would that be self-indulgent CF1?  Or would it be virtuous CF2?

Again, that’s not to compare myself to Apple or Amazon, and maybe that’s a crappy example.  But I find myself rooting for Bezos as he takes over WaPo.  There are a lot of changes he can make, and he should be the arbiter!  (One – get rid of Jennifer Rosen, por favor.)  He should find top people there and elsewhere – Jobs’ formula wasn’t to find just better engineers, but ten times better engineers, A++ engineers.  And then team with them and work really hard for a vision that works, time and time again, if that’s where his heart is.

Yes, you have to make compromises because people are people and you can’t get everything exactly right every time all by yourself.  But let’s not surrender to worries about CF1 when you are a CF2.  

Budd Shenkin

Another Afternoon in the Pediatric Office

As doctors, we bring our ideals, we bring our training, and we bring ourselves.

The simplest is our ideals.  “To do good,” that’s pretty much it.  Hippocrates’ famous dictum “Do no harm,” is cautionary.  He was wise to caution, because doctors have an inherent predilection to act, to do something, which is why he says, “First, think, what’s the downside?”  “Do no harm” is more quotable, however.  But that’s translated from ancient Greek.  Before the translation, who knows, it could have been, “WTF?”

Medical professional training is less simple than our ideals, and with medical advances the technical training gets harder and harder and longer and longer.  I suspect, but it may not be true, that all the technical training has crowded out training in how to actually be a doctor.  Empathy, understanding, judgment – I’m pretty sure this has to be taught by people actually experienced in being real doctors, not just medical educators.  It has to be personal, in small groups or individually, and it’s mostly look at the way I do it. 

I admire the doctors who really tend to teaching the next generation personally.  I went to one of the best foot orthopedists in the country yesterday, and he had a young woman with him who must have been a resident – so young, oh so young! After he saw me I saw him in the hallway explaining to her, one on one.  This guy is more emeritus than I am, and here he is, passing along his art, the way he does it, the way he understands it, for no payment or recognition whatsoever.  Who knows what he was telling her?  About the foot?  Or about how other doctors – and me, the patient – got the diagnosis wrong.  If it had been my father there in the hallway, I know he would have emphasized the latter.  This guy is old school, so maybe that was what he was doing, too.

And finally, besides ideals and training, we bring ourselves.  We have our own experiences, our own understanding of life that is often hard won, and if we are good doctors, we will pass this on.

Last Monday I used this last tool, myself, and I hope I didn’t do any harm.  Two brothers ages 12 and 13 came to see me for their first visit, just for checkups.  They were brought by their stepmother; their divorced mother and father had both remarried and share custody.  The older boy is at his Mom’s in San Francisco Monday and Tuesday, then over to his Dad’s in Oakland.  The younger one goes to another school and so is at his Mom’s Monday through Friday, as I understood it.  I had a shock of recognition when I heard this, since I shared custody of my two eldest sons with my ex-wife for years and years, splitting up the weeks and having the kids travel back and forth.  I told them I was familiar with their situation and observed that it must be a hard for them.  Or, as their stepmother put it, “The Backpacks.”

In a checkup visit, I try to do some good.  I can do it with prevention – I always deal with exercise, usually with nutrition, etc.  But I bring myself to the visit, and try to figure out how they can leave the room better off than when they came in, rather than a simple “everything’s fine.”  So, since there were no obvious health issues, I persisted in asking them if the schedule was working for them, even though it’s hard.  The stepmother, a nice lady who commented on their and her Myers-Briggs typology, so she’s pretty aware, said “No, it doesn’t.  It’s really a lot of driving, but we make it work.”  Hard on her, clearly, as well as them.  But she was honest and clearly determined to overcome barriers.  One barrier being that the younger one is INT (introverted thinking) and J, so she finds it hard to make contact.

I don’t have a lot of time in these visits, so I tend to shoot things out and hope they work.  I immediately told them that I was divorced also and had shared custody of two boys, which led the stepmother to say, “Maybe you will be able to help us some, then.”  Maybe so.  I had to save time, so I just preemptively said, hoping it would help to frame the situation well, that it might be difficult going back and forth, but it’s a lot better than having to feel deserted by one or the other parent.  Maybe it helped, maybe it didn’t.  Maybe that will resonate.

Later when I was alone with the younger boy I asked him if everyone got along OK, assuring him everything was confidential, as I always do.  He said that he felt that they two boys were asked to clean up the house at his Dad and stepmother’s house, and he didn’t think it was fair, since she was the one who messed it up the most.  I asked him if he could talk about this to his Dad or stepmother and he said, not really.  Do you have anyone to talk to about it?  “My mom,” he said.

The plot thickened – I know this pattern.  So I asked him, “What does your Mom say when you tell her about it?” I asked.

He said, “She says, ‘Well, I guess you should live here with me.’”

I’m so proud that I didn’t comment directly on this.  I was hoping I could bring my best self to this visit.  So, I asked if I could try to help this situation a little.  He said yes.  I told him that it would be best if he could bring up complaints about his Dad’s house directly to them without fear of repercussions.  I went through with him how he could first say something good – maybe how he appreciates how his stepmother cooks for them – and then tag on the complaint.

“She doesn’t cook,” he said.

Right.  “Well,” I said, ”maybe you could say how much you appreciate all the driving she does back and forth?”  Yes, he thought that was valid; I don’t think he had really thought about that, about how hard his stepmother tries.

Then I asked him if I could help by bringing up the issue in a way that couldn’t be traced back to him.  He trusted me and said OK.

So when I got the three of them back in the room, I traded on our common experience to say to them that they might think about having some meetings as a family together, where they could say what was working well, and what was a problem.  The stepmother said, we just had a meeting on Friday, but that was over a problem; maybe it’s a good idea to have one where we can say good things.  I said I thought that was important.  The younger boy kind of looked at his stepmother sideways, warily, but I knew he knew that I was doing what I said I would, and had carried it out OK.

Hard to know what will happen.  Easy to conceptualize, hard to do, especially with the subterranean undermining mother.  Although I understand her.  It’s so hard not to have your kids all the time.  I was watching old videos of our family as I copy them to disk.  My kids stayed at their Mom’s Christmas Eve and early on Christmas morning, but were expected at our house at 10 AM, when their stepbrother, stepsister, and half-brother would also be there for opening presents.  How hard it had to be for their mother to say goodbye to them on Christmas morning.  And how hard it would have been for me not to see them.  I know, because as time went on I didn’t see them anymore for Christmas. 

Divorce just sucks.  I just hope that what I did with these two boys and their stepmother helped in some little way.  At least they know they are not alone, and maybe something I said helped.  Like I say, ideals are important, training sometimes helps, experience certainly helps, but bringing yourself to the visit might be the most important thing of all.

Budd Shenkin

Violence and Climate Change

An "I told you so" moment - how I love them!  In fact, that was a large part of the reason I started this blog, truth be told.  If I'm right early, I want the credit.  Get those A's, young man!  I don't think I'll ever get it out of my system, and why try?

The point in question: in a previous blog I asserted that global warming plus population explosion will lead to more and more violence -- and even more than that, an entire change in the cultural beliefs and mores of humankind, as the conditions of existence are so severely changed that it could be called a point of inflection for the entire human culture.  The paradigms that we have been accustomed to, where the earth was big and the human race was small, will be changing.

Apocalyptic?  Yes, I guess it is.  But these are our times.

I'll have more to say on this in the next day or two, but in the meanwhile, here is collaborative evidence from the Huffington Post, via Skepticalscience.com:

Climate Change And Violence Linked

Shifts in climate change are strongly linked to human violence around the world, according to a comprehensive new study released Thursday by the University of California, Berkeley and Princeton University.

The research, which was published in Science, examined 60 previous studies from all major regions of the globe. The results suggest that changes such as drought, flood and high temperatures strongly correlate with spikes in conflict.

Researchers noted examples including increased domestic violence in India and Australia, assaults and murders in the United States and Tanzania, ethnic violence in Europe and South Asia, land invasions in Brazil, police violence in the Netherlands and civil conflicts throughout the tropics.

Climate Change And Violence Linked, Breakthrough Study Finds by Robin Wilkey, The Huffington Post, Aug 2, 2013.

Budd Shenkin