Two Weeks After The Lahaina Fire - A Day On Maui

 

Met old friend for coffee in Kihei, near son Peter's gym in the Azeka Mall. Her husband died last month, age 59. He was a realtor who sold us our first condo here on Maui. (For the sake of confidentiality, I'm going to leave out names, not that there's anything super-secret, just being a little discreet.) After we bought the condo he became our friend, especially Ann's. He told us that he looked on us as his preferred parents, since his home life back in Europe had always been a mess. He lived here in Maui for about 25 years, I guess. We saw less of him when Ann got sick, and then COVID, but then after Ann died I had coffee with him at that same coffee house. Then on July 27 he was riding his bike with two friends down from Haleakala and there was a line up of cars coming up in the opposite lane and and a jeep tried to pass then all. His two friends riding ahead of him bailed out but he was third in line and probably didn't see him coming, so he was killed. It was pretty horrible.

His wife, 64, is putting pieces back together. We had our coffee and talked. Having dead spouses gives us something in common. We do what people who have lost spouses do, I guess – we reviewed our lives chronologically, the mistakes of our first marriages, the second ones a lot better, both better choices and more informed and patient efforts. She said, eventually as we talked, as though realizing it for the first time, the only time tears appeared, He was the love of my life. Not saying, and now he's gone. Maybe she also felt that at least she had had that, and has that. She said that the last three months might have been the happiest time of his life. He thought that he had done well enough, that he had enough, that he didn't need to do better or have more.

At our last coffee, he had told me about his new responsibilities as husband and father of two young adult girls. He seemed surprised a little at his new responsibilities, as husband and father, and surprised at how well he was meeting them. He was modest about it, just kind of confided in me. Now, his wife – I so hesitate to say his widow, but that's what she is, so abruptly, and although they never officially married, that's what they were to each other, spouses – confirmed that in spades. He had reached out to the younger daughter, whom she as the mother couldn't reach, and he found her responsive. He had told me that he worked so hard on her that it was hard for him to do his real estate work. Now that he is gone from their lives, the daughter tells her mother that if she want to drink, she doesn't, because she remembers him, and is being faithful to his memory – he wouldn't want her to. The mother and two daughters agree, it was the wrong father who died; if the original one had, they would have said, well, no surprise. And implied, no great loss. How unexpected how everything turned out, the new good father and the wrong death.

When she had gotten divorced, in her 50's with two teenagers, she had thought, well, the odds of finding someone else were slim, but she and he knew each other within the real estate industry and they gravitated to each other. He had been careless – no insurance, little savings, no will, no retirement. She fixed that. He grew up. She even had him go to the doctor – he had a check up in May, all OK. That will help in the lawsuit, lots of years left. They had been together ten years. Just ten years. How do you know it's the best ten years of your life when you are living it?

She is directing her anger at the bureaucracy that delayed telling her that he was dead even though everyone else seemed to know, but the police had cautioned them not to tell her, to let them do it, but they were slow, so slow that she got a condolence call before they actually told her at about 4:30. The accident had been at about 11:15 or 11:30. Write it off as inefficiency, everyone was trying to do their best. But still.

She will have to sell their house. She's close with her step-father, who has been kind of lost himself, but she buoys him up. He's out here in Maui now; maybe they'll find a house for the two of them. She thinks that that's it for her and men – no more now. But I think – you never know. She has friends – I told her I have some friends, too, some guys, but she said that's nice, but men aren't like women when it comes to friends, and of course she's right. I told her it really took me nearly a year and a half to feel recovered, even though I didn't realize I wasn't all there until I actually felt better. I don't think there's anything you have to do, except keep in good shape and busy; then one day all of a sudden you start feeling better, body and soul both. You have to settle with yourself that it's not disloyal to feel OK. “Time heals” must be right. There's a lot going on as time is healing, of course, but I've chosen not to pay too much attention, just let it happen. I trust my unconscious, it doesn't need my help.

She has beautiful blue eyes; she knows she's good looking. I told her to get in touch if she every wants to do something together. Not romance, but it's good to have friends. She said let me know when you're in town. Neither of us wants anything more than friends, although I did tell her I miss being in love (sometimes, anyway.) Maybe it's strange for a man to say that, but I've spent a lot of time with women – I was a pediatrician, after all – and I like girls and women, so I feel at home with them and I can say stuff like that.

Then we hugged tight and left the coffee shop and in the parking lot an older lady with gray hair and a lively voice was driving by and stopped and asked me the way to Foodland. I'm the kind of person that people stop and ask, I guess. Older but not doddering, respectable, in gym shorts and looking sharp, for a change. I directed her and she said, answering the unasked question of what a lady like that was doing asking for directions to Foodland, I'm from Lahaina.  She nodded toward the back seat and there was a large canvas with a painting of the Capitol Building in DC.  She said to me, "Biden's here today.  Maybe if I meet him he can take this and sell it and I can get some money.  It's what I grabbed.  I probably should have grabbed the Hawaii paintings."  I think I said something like, well, who knew, or something like that.  I wanted to do something appropriate to help a refugee, grab her and hug her, to be very dramatic, or say what can I do, but she probably wondered what she was doing talking to a perfect stranger like that, and drove off with what I think was a wistful smile.

It was a nice day.  I dropped by the always nice Kihei DMV office (strange for a DMV office, but true, intimate, friendly, efficient) to reregister the car but there was a note taped to the glass door that the office was closed because of lack of personnel.  No dates given, but I think it was just put up there today.  I always liked this little office, and I wonder if it will reopen.

I drove home, ate a little, saw Peter who then went to work, and took a nap.

Life is a pretty strange experience, all in all.

Budd Shenkin

Lahaina A Total Tragedy, Don't Let South Maui Be Collateral Damage

 

Dear Governor Green,

Greetings Governor, my name is Peter Shenkin and I am a 39 year old Kihei resident, an attorney, and business owner on Maui in the town of Kihei. I am the owner of Maui Powerhouse Gym in Kihei, with 41 employees and 3,000 local resident full-time members.

Sir, I am writing to your office this evening because I am concerned by the unintended consequences of omissions to your messaging during statements and appearances on social media and national television. I think you have done a wonderful job exhibiting leadership during the current crisis showing patience, kindness, and sensitivity. I hate to offer constructive strategic criticism at this time and would not do so if I believed that it could wait. Sir, with all due respect, I believe that you are erring strategically by not directly addressing future visitors to Maui and alleviating their confusion over travel to South Maui over the next quarter.

My recommendation, Governor Green, is that you please openly and clearly encourage visitors to the island to continue their trip to South Maui starting in September. Encourage the visitors to show their support for the island by visiting Maui and remaining in South and Central Maui during their stay. Your messaging would assist in mitigating cancelled reservations for the Fall and Winter by reminding people that South Maui is open for business and that traveling here is OK and encouraged, and also morally allowable.

My fear, sir, is that your current messaging is not setting a clearly acceptable timeline for when visitors may return to Maui without moral consternation. As you are well aware, the resident population of South Maui is entirely dependent on tourism revenue for their livelihoods. You and I are both also acutely aware that the incoming wave of cancellations will devastate the local economy. Measures should be taken to minimize those damages and their effects. The most conspicuous means of mitigation would, I believe, be direct and vocal messaging on national media through your office and the Mayor's office. For political cover you could cite Mayor Bissen who has acknowledged several times that "Maui is open for business, you can go to South Maui, do not go to West Maui." For even more cover, you should nudge Mayor Bissen to start protecting his South Maui electorate and their jobs on National TV.

The zeitgeist on the mainland is currently: "if you visit Maui you are a terrible person," "DO NOT VISIT MAUI IN 2023", and other similar slogans. These populist messages intend to be protective of the victims and the island residents, which is admirable, but they could potentially be deeply harmful to small businesses in Kihei, like mine. If these messages are successful, I sincerely fear a return to doing business similar to June - September 2020 when there was zero visitor revenue at all that will last into early 2024. Doing business in that type of environment would be tremendously challenging for a successful business like mine but could be existentially difficult for the food trucks, restaurants, snorkel tours, surf schools, and other small businesses that are not as sophisticated or well-girded. I truly fear for their existence if this shutdown lasts for too long, sir.  

You may not be aware sir that commercial rent in Kihei is comparable to midtown Manhattan prices. Kihei businesses cannot afford a fourth quarter with a thirty to forty percent reduction in revenue without a bailout. It would be a shame to see this happen when the preventative measures cost nothing to taxpayers and easily accomplished through words alone.

Governor Green, we are all hurting very deeply right now. We need you to protect the future of South Maui by being mindful and protective of our fragile local economy going forward and ensuring its viability.

Reach out anytime. Thank you for your time. 

Sincerely Yours, 

Peter Shenkin, Esq.

Oppie

 

I was interested to go to see Oppenheimer, but then I was reluctant to make it my first movie visit in maybe five years. Then when my friend Benj wondered if I might review it for him for his on line periodical First of the Month, I was willing to fight the obstacles. The full houses that put off my seeing it for a week; the new technology of being ticketed on-line which led to double booking for my seat J-19 and kept me expectantly waiting for the rightful owner of the empty seat J-16, where I had perched, to appear and claim the seat. When we got to 2:30 I thought I was home free until I realized all the mindless previews only ended at 2:55, but I managed to stay where I was unimpeded. And then the new technology for paying for parking which involved loading an app and getting a movie employee to enable the scanning machine to get my voucher recognized. Good thing I had time, nowhere to go, it was summer and so still light outside. Yet, I had to wonder yet again, is advancing technology worth it? How appropriate.

(Not to mention that for a half-hour lead in and a three-hour film, I got so uncomfortable later on that I had to leave momentarily to visit the bathroom, about when Kitty faces the inquisition committee that ultimately nixed renewing Oppie's security clearance, so I won't be commenting on that, except that "inquisition" is the right word in these very religious rites. We get so comfortable with streaming, bathroom and refrigerator nearby, pause button at the ready.)

But forget all that. Benj had suggested I review Oppenheimer because of my unquestionable credentials – security, science, movies, and taste for men who love women. That was too much of an inducement to ignore. And then, despite Nolan's once again, as in Dunkirk, overusing loud, insistent music that sometimes drowns out dialogue, this is a brilliant, even genius movie. He's making a familiar story into myth, in the best way possible, in the new technological advance over literature, the movies.  A technology that was itself questioned by lovers of books, although now that books and movies comfortably co-exist, the bleats of objection are muted.)

It could only be told by interweaving the later time plot line of (1) trying to renew Oppie's clearance followed by Strauss's failure to be confirmed by the Senate for a post in Eisenhower's cabinet, and moving back and forth to (2) Oppie's personal history and the well-known Manhattan project trajectory. A straight chronological time line would have been deadly; the script is just brilliant at heading to two climaxes simultaneously. (And, after all, we're dealing with physics here, and the imponderablity of time running only one way and the undecipherability of quantum physics, so moving time around is altogether appropriate.) The use of black and white for the post war plot line, and full color for the sunnier times of war and fighting fascists, is once again brilliant. The McCarthy era deserves nothing more than black and white, truth and myth over reality let's not uplift emotions for those guys. One reviewer regretted that the full depth of Oppenheimer's genius for languages and art went unplumbed, but to my mind, just alluding to it was startling and revealing, and the unstated depths were just the back story you can get if you read the books. The man was a genius, folks, and that's what geniuses do. But it doesn't mean they're good at relationships or politics, let's get that straight. Here in the movie, the allusions were perfect, and that's what is great about movies, the small items, hardly even noticed, that you have to take real time to allude to in books.

And then the mixing of the personalities, the human stories, and the science. The picture of individuals with all their weaknesses and evil – their humanness – unlocking the locked boxes of the gods, the knowledge, the Furies. That's really what it is.

The scientists are, well, scientists. They are like the people who think that explaining the facts will make Red states get vaccinated. Oppie argues with facts to make his case for his personal survival and resurrection and conquering his foes, no strategy but that, “if I only explain to them.” His wife says, fight! She smells out Strauss for the jackal he is, and what a performance by Robert Downey Jr. It might be his best performance ever, and it's brilliantly written as the truth only gradually becomes apparent – it had me distrusting what I knew about his being awful when I experienced the time as a young teenager, was I wrong? Downey plays it perfectly, as finally the truth of his petty perfidy and consummate skills as a bureaucratic infighter come out, in black and white as it should be.

Nolan makes the whole story mythic, how the power was unleashed by people who all saw only slivers of the picture. Scientists as technicians who think they know more than that, political and military figures who know more than the scientists about uses but have less vision of what is possible, perhaps, or perhaps more vision of what is realistic in international relations. It could be this way, we could trust each other and find a common path to peace, says Oppie. I didn't see it in the movie, maybe I missed it, but Einstein said to him, don't you see, they need you, you don't need them, walk away. But then, that's Einstein, with his weaknesses for the reality of everyday life and love that we saw in the series where he can't handle women. Einstein dives back into his private life of contemplating sitting on light beams and feeding ducks, but Oppie can't do that, he's involved, which isn't to say he knows how to play the game. Einstein thinks he's foolish for that, I think Oppie has the impulse to be more socially responsible than Einstein. But people are different.

And then there are the sex scenes – brief but enjoyable, prolonged look at female nudity without shame or desire – the burden that wife Kitty has to bear with this husband whose capacity for showing affection might be limited but whose libido is not, and she's had her own troubles, of course. I think people tend to treat the foibles of the scientists with less compassion than they should; if it were a straight love story, we would, but here it's just backdrop to the main issue of the unlocking of the secrets of the gods by mortals, so compassion for foibles is in short supply. People just open the damn locked box because they are people.

The picture we get of a scientific genius becoming an organizational genius who bumbles through his private life (although he's shown as very brave politically in resisting social pressure to join the Party,) of the times when smart scientists thought life could be organized scientifically as socialism because it was reasonable, of the politicians who don't realize that it's not a new weapon it's a new world – all this makes you think, how can Armageddon not happen, one way or the other? An unanswered question, likely for all time, until it's decided unfavorably, and then we know. (See my review of the final book of Dan Ellsberg – a review that Ellsberg himself liked a lot – here http://buddshenkin.blogspot.com/2018/02/ellsbergs-doomsday-machine.html).

It's not disrespectful to make these events into a story, into myth. The spectacular use of special effects, prospects of dead and disfigured people in blanched-out flashes as projections of Oppie's vision of crazy guilt or seer's vision of reality as seen by gods, is appropriate and not overdone, as it could well have been. The quieting in the soundtrack of screaming crowds and explosions you half-expect to see, the counterpoint to the insistent music (that, again, I didn't like any better here than in Dunkirk), that's fine, too. Not too flashy for flashy's sake, more masterful, I'd say.

So, finally, a brilliant movie that I was set to dislike. Maybe one of the great ones. Just goes to show you – don't predict, let them play the game. 

Budd Shenkin

A Baby And A Rolls-Royce

I needed a job. I had run out of fellowships, I had run out of local academic positions that didn't pay anything anyway, I had a new wife, two kids, two step-kids, and I needed a job. I didn't really know how to practice pediatrics, the way a new lawyer doesn't really know how to practice law when he or she starts, but it was something I could do at the beginning well enough not to kill anyone, and I would learn. So I started being a pediatrician.

My two new colleagues in Oakland needed someone to be on-call with them. Nights and weekends needed to be covered, and their third on-call pediatrician was leaving independent practice to join a newly forming group that Peralta Hospital had been persuaded to back, even building a new office building for the group right there on Oakland's so-called Pill Hill, where three hospitals were within a block of each other. In time, of course, the three hospitals would merge into one, then be bought by regional powerhouse Sutter Healthcare, and the new group would fail, and I would move with my new small pediatric group into one of the offices in the new building – but that was ten years in the future. For now, one of my new associates, John, needed someone to occupy the other suite in the small, one story office building that he owned, and he and Bruce, with an office around the corner, needed that third on-call slot filled. They needed me, I needed a job, so we had to strike a deal. Luckily I had some money so I could ease into practice slowly and not worry about loans. My independent means also gave me some class in their eyes, and of course, I always had my swagger, the Big Shot, as my father would say. But really, I had never thought about being in solo practice, and I had no idea what awaited me.

Part of our deal was reduced rent for six months or so, and they would introduce me to their referring doctors so I could start picking up patients. John and Bruce didn't want me to siphon off their private patients, so they made sure to introduce me to the OB's with a lot of Medi-Cal patients, along with some privates. They took me over to the hospital to the doctors' lunch area in the cafeteria and introduced me around. And that's how I met Jim Cadwallader.

Jim and his OB associate Ned Nuddleman weren't partners, but they worked together, assisting each other for C-Sections and splitting call. Bruce and John had enough Medi-Cal patients and could spare those patients that Jim and Ned would refer to them. That was the pattern as you got more successful, let the Medi-cal go and load up on privates if you could. Later on, as I got successful on my own, I changed that pattern and kept my Medi-cal patients, and instead hired associates to help with an enlarging practice, but that's another story.

If Jim's unusual last name seems familiar, you might recognize it from a little throwaway line in The Philadelphia Story, uttered by Cary Grant, in his ultimately winning way. (What an actor, Cary Grant!) His character was top of the heap on the Philadelphia Main Line, old established rich, and he mentions “the Cadwalladers” as others of his ilk. You have to listen hard to hear it, but it's there. The Philadelphia Cadwalladers, poshest of the posh. And right here, on Pill Hill in Oakland, was a verified Cadwallader. Although I soon found out that this Cadwallader – a little above average in height, an attractive round face with dark hair and rather clear light skin, with many a smile but also some lingering insecurity – was definitely not top of the heap at Merritt, and was not from Philadelphia, but from Nebraska. Was he related to the Philadelphia Cadwalladers? Not that we knew, but it's not that common and name, and who knows? Every family has its black sheep, the ones who find their way to, say, Nebraska, whose offspring might get medical degrees and find themselves serving Medi-Cal patients in Oakland, California, don't they? I thought they must.

And Jim definitely qualified as an eccentric sort. He looked good, he dressed well, we hit it off at once – he told me later, “didn't you just feel it?” – and he liked to laugh. But he wasn't married, and he was insecure, that's something you certainly could feel. He tended to look anxiously left and right. Someone who seemed to need a friend. And sure enough, we did become friends, often waiting together with Nuddleman during the night for an OR to open up so that he and Ned could do their C-section and I could catch the baby. We weren't fast and close friends, but he did invite us to parties given by his considerably older girl friend Ethyl, who lived in a huge house in Burlingame, which Ethyl had owned since her rich husband had died some years before. They were an interesting pair, they kind of adopted Ann and me, then newly-married and both much younger than Ethyl, as we sought to establish some kind of social life, as I was establishing a new professional life.

As I look back on it now, it was hairy. I really didn't know what I was doing, just winging it day by day, having a job, although I did think that I had to learn to do this job before I could make it a thriving business with a group of doctors, I hardly even thought of these future doctors as employees, too bold a thought, but it was there. And Ann and I were making our way together, both having divorced our spouses to be together, hoping it would work, because we had bet a lot and hurt other people to live our dream.

So anyway, Jim and I became friends and he referred patients to me and I did a better and better job with them. But in practice, you never know what will happen, and sure enough, a couple of years into it, one bright morning in the office I got a call from him. He sounded excited and challenged. He had gotten a call from someone, probably his patient, who had a daughter who lived at home and who was a college student at Cal. What had happened was, that morning her daughter had gone into the bathroom and had a baby. Jim's patient and her husband didn't even know that their live at home daughter was pregnant, so it was more than a surprise. They didn't know what to do, so they called Jim. He said that he was going to get the new mother into the office and examine her to make sure she was all right, and would I examine the baby? Sure I would.

So, next thing I knew, just maybe a half hour later, Jim was driving into our parking lot with the new mother, the new grandfather, and the new baby. Oh, yes, I forgot to say, one of Jim's eccentricities was that he liked to drive nice cars. His car was a Rolls-Royce. So he rolls into our parking lot in his Rolls and they all pile into my little office. What a scene! The baby's grandfather was Chinese with a rather thick accent, clearly an immigrant. The new mother was an attractive young college student, and as I examined that baby girl, I discovered that she was a normal newborn, a healthy and beautiful newborn. What should we do? I said to Jim, well, the baby's normal, they could go home. Nope, said Jim. Born at home, non-sterile conditions, let's admit them both to the hospital and watch for a while, which we did. Back up to Merritt, our home base, into our OB ward and the nursery, and we were all comfortable.

But then Jim said, what should we do with the baby? We didn't know what their plans were, and as it had all come as a sudden surprise, we figured that they didn't have any plans. So, here's the amazing thing. Just a couple of months previously, one of our hospital colleagues, Revels was his name, an internist with a specialty in pulmonology, had approached me. Revels was an operator, always with an angle and always well and even nattily dressed, a light skinned black man with origins in Mississippi and a civil rights family background, with a beautiful and classy Chinese-American wife. Revels had asked me a question that I had never been asked before and would never be asked again. He asked me if I sometimes came across babies who needed to be adopted. He and his wife could not have babies and they had decided to adopt. I had told him that I would look out for him, but that's it's not something that usually comes up for me.

So, when Jim asked me what do we do with the baby, I naturally thought of Revels and his wife. What a set up! An asian baby for a half-asian couple, a college student mother so the baby would probably be intelligent, and no waiting time on a list of prospective adoptive couples. The hand of God, I would think if I believed in God. We approached the family, Jim and I, and they seemed receptive to the adoption idea, so I put in the word for Revels. Revels was beside himself at the find, told me of course I would be his pediatrician of choice (strange that he would say that, I thought, but I figured that I was not top of the heap in pediatrics at Merritt – yet – and it was a concession to me on his part) and the deal was made. Adoption is not a final decision in California until six months had passed, and such was Revels anxiety that he was after me repeatedly during that six months period, was the mother wavering? Of course I wasn't seeing the mother, but I still reassured Revels, I can understand your anxiety, but I think it's going through. Which indeed it did, and Jim and I counted ourselves heroes in this excellent adventure.

I never got a chance to check on the Chinese family, wondering what happened to them. From our point of view, Jim and me and Revels, it had gone great. I don't know about the mother. When mothers give babies up for adoption there are always little or bigger scars, second thoughts for a long time, no matter how much they know it's the right thing to do. I never saw her again, so I don't know.

Then there's the father of the new mother, the grandfather. What a day he had! He was a tender man with a heavy Chinese accent, clearly an immigrant who seemed to have made a wonderful transition to America with an achieving daughter, despite this misadventure. After all the commotion that had ended with both mother and baby at Merritt Hospital for a few days for observation, we drove away in Jim's Rolls with me in the passenger seat and the new grandfather in the back seat. He looked around and summed it up for us. “What a day!” he said. “First my daughter has a baby and I didn't even know she was pregnant, and then I get to ride in a Rolls-Royce!” Jim and I looked at each other and kind of chuckled.

You just don't know what you're going to find, when you go into practice in the community, you just never know. You make friends, you meet all kinds of people, you share in life's adventures. I did get to see what happened to the baby. She grew up to be a lovely and accomplished young woman whose parents doted on her. When she got into the school years, Revels and his wife switched her away to my colleague Bruce for pediatric care. Bruce had higher prestige around the hospital, but that's the way it goes. Revels was an operator.

Budd Shenkin

Catcher in the Rye and Streetcar Named Desire

 

To Love Without Knowing

I always find it kind of amazing to find out how little I know.

I can go through life loving something, being attracted to something, recommending something to others, and then I realize that I really didn't understand it in the first place. I am saved only by the fact that others have been in the same state. We might have liked something, been attracted to something, been able to talk about it, but then something happens and I realize that we reallydidn't understand it, not really. In fact, the more I think about it, the more I think we like (or dislike) much more than we understand.

I'm thinking about books and movies, two pastimes, sometimes obsessions, and sometimes loves. When something grabs me, – that's the word, when something grabs me, I just grab it back. Eventually we let go of each other, but even then, the memory stays. Even if it was a youthful attraction – the Hardy Boys, say – and you realize you were an immature appreciator of a work aimed at the immature, still, the good feeling remains. Or even before that, A. A. Milne and Christopher Robin and Pooh. And then in my mid-teen years, when I felt so good about having become a good reader, and I reveled in being able to just go through books, I briefly read science fiction. Lester Del Ray – what a name! He had to have been born to write science fiction, Lester Del Ray. It was a brief infatuation, but the good feelings remain, and some of the memories – exploring around the place of your birth to discover you lived in a sphere in space that had been expelled from Earth. Can't forget that one.

But some books are loves that haunt, and stay, and you love, but maybe you don't really understand. Like that old trusty book now become a standard, so standard that current young people can say to my surprise, “I hated that book they made us read!” They made you read that book, the one my mother gave me, recommended to me, only five or six years after it was written, that was even somewhat subversive – my mother liked somewhat subversive books. Or at least intelligent books, which some people suspect of being subversive just because of that quality. Catcher in the Rye. I read it when it didn't have the disadvantage of having been recommended and assigned, so it had the air of discovery. It's not secret now, but when I first read it, I think I was the only one of my friends who did. My mother was responsible for so much of my discoveries of books. I myself discovered Word Power Made Easy, which I still love, but that's such a minor discovery compared to all the books my mother gave me to read.

Holden was haunting, who couldn't root for him, identify with him? I sided with his denouncing phonies even though when I read the book I had not yet met a real preppie. That came several years later, when I was a freshman at Harvard, and I guess I saw then what he was talking about. The accents, the attitudes, even the nice ones, John Erdman who was a nice boy my age but came from Hotchkiss Academy and affected a tweed jacket and, wait for it, a pipe. Eighteen years old in a tweed jacket and with a pipe. Ivan Light tried the same shit, a pipe. And John was taking advanced French literature as a freshman, he said with his deprecating and experienced voice, and he was only eighteen, and I was envious. He was nice, actually, he just had these affectations, which maybe affected him more than others. They said he was depressive, afterwards they said that, anyway, after we went to medical school together and he became a heart surgeon – why did you do that, John? – and I guess he was good enough to go to the Mass General but long after I had left Boston, while he was still in training, he was ready to fly on his own and he opened up a chest to do an operation but, for some reason that was only described to me as fear, he didn't follow through with doing the operation and he just closed the chest back up, without doing anything, and hooked himself up to an IV and lay down, I imagine on a gurney, and killed himself. He was a nice person, he was smart, although affected, but nice, somewhat less than average size, pursed lips it seemed, formal, preppie. I wouldn't have known he was Jewish if someone hadn't told me. I don't know if he had pimples, probably not, but I tend to think of him as having had pimples because that's the way Holden Caulfield described The Makeout King, I think it was, although John was nothing like The Makeout King. Phonies, Holden hated that. That's what I guess I thought the book was about, even though Holden wound up in a mental hospital at the end of the book, which I didn't understand, and his closest friend was probably his little sister Phoebe. That's an unusual name these days, but when you meet a Phoebe, or you hear of one, do you think of Holden's sister? I do, even when I don't consciously do it. It's a name I pay attention to.

But what I was saying before I got diverted, or at least I think I got diverted, was that you can love something and be influenced by it, or seduced by it for reasons you might not be able to describe, or even haunted by it, and not understand it, or maybe understand it and not know that you do, because you can't express it, or maybe it's an unconscious understanding, a non-verbal understanding of a purely verbal medium, books. So when Catcher in the Rye was fifty years old Louis Menand wrote in the New Yorker Holden at Fifty. The book is so famous you can just use the first name of the protagonist. Louis Menand is so very smart, he's one of those writers that if you see his name, just read it.

So I read the review and I realized, for all my love of the book, for the attention I had paid to it, even writing a tiresome paper about it in David Riesman's class at Harvard, I realized that I didn't understand the first thing about it. Because the first thing about it is his brother Allie died, and Holden just couldn't come to terms with it. “Come to terms.” That's quite an expression, isn't it? “Get over it.” “Wrap his arms around it.” Instead, he goes nuts. He tries to work it out with Phoebe, but he goes nuts, although he does emerge eventually. And where are the parents? Parents – they never get over a death of a child, do they? Or not nowadays, maybe. More kids died than survived originally, some societies didn't even name kids until they were two years old. Lincoln lost Willie, his favorite, right in the middle of the Civil War, and he was depressive to begin with, they say. And I couldn't even realize that, as Menand says, that's what it's all about. I just don't understand literature, I think. Although I did, for reasons that I never really understood, name my firstborn child Alexander, to be called Allie. Allie – why choose that? I always said that I named him after Holden Caulfield's older brother who died, and the Yankee righthander Allie Reynolds, although that must have just popped into my mind, because if anyone knows me, they know I'm a born and bred and nurtured Yankee hater, from Philadelphia. So Reynolds was just an afterthought. I think maybe I did understand more than I knew, because choosing that name is like repairing Holden's sanity. But what did I know?

I've also always loved my favorite playwright's best movie, Tennessee Williams's Streetcar Named Desire, which I watched the other night. I'm pretty sure I never really understood it, maybe don't understand it now. I'm pretty sure I've watched it more than I've read Catcher in the Rye. Movies are short, but so concentrated. It doesn't take long to describe an atmosphere, it just appears. You choose black and white sometimes even when color is available. Eddie Muller on TCM quotes someone who says, color is more realistic, but black and white is more truthful, or something like that. Black and white is so intense, especially when there are lots of shadows and streaks of sunlight, like a Tintoretto. Somehow black and white concentrates the feelings, I think.

I've always felt Streetcar was one of the very great movies, a true movie, even though it deals with so much invention and pretension. I think if you're not in a class and you don't have to think about it and talk about it, maybe you don't come to terms with it. So I guess I didn't. I liked Marlon Brando, I could sense all the tension, I heard people remark on his brutality, and everyone yells “Stella” when you start to talk about it. Why is that? It's so startling, is that it, striking? Or is it embarrassing, it's so stark. And you think about Blanche, played by Vivian Leigh, and her feeble pretensions and her sordid past about which she lies. And you think about Mitch, played by Karl Malden, his frustrations living with his mother, seeing a chance to break through his limits with Blanche, and then finding out about her lies. Finding out because Stanley (Brando) makes it his business to find out that she had turned to whoring, that she had seduced the wrong young man and had gotten thrown out of her town. I had to tell him, Stanley tells Stella, he was with me in the war! What was he going to do, sit on it? But why did he inquire, because he hated her, or because her seductiveness caused him so much confusion?

The quietest of the group, the one with the least screen time, the least demonstrative, is Stella herself, played by Kim Hunter. When I saw it this time, her dilemma is what hit me hardest for the first time. What would anyone do in her situation? You love your husband, you are having a baby for the first time, a huge event, and your older sister comes to visit, as a last resort in saving her life. Sisters can't turn each other away. Stella is caught in a vise. She can't deny her sister, she can't deny her husband, and she's having a baby. You see your household falling apart, but what can you do?

Stanley has been called a brute, but he's not. What is he going to do? He loves his wife, he needs his wife, and he can't stand her sister's invasion, he can't stand her, and she's there for months with no signs of leaving. He could let Mitch take her, but that would be craven – poor Mitch, how can he let that happen? His wife's crazy, lying, seductive sister. And Mitch is caught, too – why does the truth have to raise it's ugly head? If it didn't, he could solve his own problem, no woman and home with Mama. Can you imagine what would happen to Mitch with his friends if he ignored Blanche's lies?

And what is Blanche to do? She wound up at her last resort. She has run out of options. Her dilemma is that she can't do anything, she has to rely on others, and she must hope that they will be kind.

In Streetcar, everyone has impossible choices.

Sometimes the only solution is to bulldoze things through, and Stanley is the bulldozer. Don't ignore the truth, don't wait for “things to work themselves out,” don't wait for others to act, it takes a bull. But to be the solver, he will also be the heavy. To solve these problems, someone must suffer. Or maybe everyone will suffer, because that's what happens with dilemmas, especially with quadruple dilemmas. But then, everyone hates you for it. Mitch is left with his problem, Blanche has to go with all her pretensions. Stella has failed her sister and hates her husband for it. And Stanley is left hoping that he will be forgiven and his marriage will be restored. Because the central truth of the movie is the love between Stanley and Stella. It's why it's so appropriate that everyone remembers “Stella!” What is it about those cries, repeated throughout the movie? Brando's cries are a mixture of insistence and plea, with his aggression, yes, but with his insistent need. Mitch knows they love each other desperately – everyone knows. She says she'll never be with Stanley again, but whenever she says it, even at the end, you know it's not true, it can't be.

So in the end, faced with all the dilemmas, the brutal insistence of love puts itself forward. But you get the feeling, and this is Tennessee's genius, you can't imagine anyone doing anything else. It's all as insistent as a Greek play, the insistence of fate and destiny which lies in ourselves and where we come from and, if you'd like to believe it, the insistence of what the gods will. Are there some of us the gods will to be crazy? Insoluble dilemmas, not brain chemistry, were posited to be the core of schizophrenia, said R. D. Laing, back in the 1970's. Seems right for Blanche.

How much control do we have? Any? We all struggle through and do the best we can. People help us along the way. The kindness of strangers, the kindness of those we know and love, the best we can do.

The gods are cruel. Our dilemmas are often hopeless.

But, on the other hand, they are also kind. For instance, how come we have been granted to right to love something, or someone, and we don't even know what it is or who it is we are loving? Why do I love Catcher in the Rye and Streetcar? I really can't tell you. But I really do love them.

Budd Shenkin

Medical Education Is A Patchy Thing

 

I've been asked a lot, first, why do you want to be a doctor, and then, why did you want to become a doctor. I've always been too concrete to say, “destiny,” which is a more positive word than “fate.” Nowadays, now that my doctoring is through – or is it? – I tend to think it was destiny, what with my father being a neurosurgeon, and with my temperament harboring kindness and with my being smart. But back then, when I was a medical student, it might have felt more like fate, although I never regretted it. Even when I felt I might not belong to the Harvard Medical School milieu, even when I was a malprepared and maladapted second year student appearing on the wards of the Beth Israel Hospital with a formal and unwelcoming Benjamin Banks as my first attending, even when the house staff were the insiders who hazed me and I was the outsider, I never thought that I didn't belong. I might not have known how to play their game yet, but it was I who belonged, because my father was a great and devoted doctor and I was a chosen and respected son, and if I perceived the BI crew as formidable and ingrown and somewhat bleak, it wasn't me who didn't fit in medicine, I figured, because one thing that I had been given by my family was self-respect, and that was never leaving me.

But that isn't to say I was ready, because I wasn't. I didn't picture myself saving anyone, or serving anyone, although being nice and essentially beneficent by nature, my brother and my sisters thought I was and family friends thought I was and I guess they mentally matched me up with their daughters, they all probably projected my being nice onto my role as a prospective doctor. But I was coddled, there is no better word for it, I guess. Not that I wasn't held to rigorous standards, I was, and I had internalized that, but it was all academics, although it was also sports. But classroom study was my thing, I excelled, my father said I could pass an exam in any subject, even if I hadn't studied it, as long as it was a multiple-choice test. Classrooms – let me at them. Tests – not a problem. Laboratories – well, not so much the hands on stuff, to tell you the truth, I was a theory guy, a words guy. Except for sports, there I was rock'em sock'em. But classroom studies, chess, my turf. My medical destiny? Maybe public health, my father drummed into me – they had a good deal going, he thought, practice was so high-tension, such a grind. Public health – all that time off, the academic postings in foreign lands, that was the greener grass to my father, and I accepted it faute de mieux.

And then, all of a sudden, there I was on the wards, real doctors and real patients and long hours. The patients were welcoming. In those days the BI had open wards, a big room with probably eight or ten beds arrayed around the periphery. When the sun came up we were there to take the daily blood tests, syringes, needles, tourniquets, test tubes in hand. One really nice black guy on the left as you came in had giant veins, and he knew he was the med student's gift. I came in and he said, “Hey, doc!” and beckoned me over and offered up his antecubital fossa – that is, the reverse side of the elbow – where giant veins stuck out like giant worms. He offered his veins as a return gift for all the care he was getting in these pre-Medicaid pre-Medicare days. Me - “doc.” Jesus, what a new world.

And then on the far wall was Mr. Marcuse, a spare and very thin little man who lived not far from the Mass General, but had wound up here at the BI. When he had appeared at Mass Eye and Ear, his chief complaint had been wax in the ears. Assigned to a medical student, a full history and physical had uncovered stomach pains in the review of systems. The doctors worked him up and determined he needed an operation for cancer of the stomach or intestines, or something, so they had operated and there had been post-op adhesions – fibrous bands had strangled his small intestines after the operation, probably performed by house staff, I guess – and he had lost pretty much all of his intestines and couldn't absorb anything and was wasting away on this ward of the BI, because he had sought help for excessive wax in the ears. No one said much about him, there was silent indications of a cautionary tale, but caution for what? Was the patient at fault for seeking care, the med student for doing a complete history, the decision to operate for what turned out to be non-cancer, the operation itself? Or a system that used human beings of the lower socioeconomic order to train doctors? No one said, but there was Mr. Marcuse stoically – or, rather, with anger suppressed – wasting away in his bed on the far wall, ready to give his history to one and all.

Looking back on it, maybe that was the shocking introduction. Or maybe it was the formal rounds where I was expected to know how to present a case, never have been taught to do so, just having seen an example or two, I guess, and only at the end adding to my succinct history, after Dr. Banks, with his little gray mustache and suit and tie bent over the patient with stethoscope in hand and in ears, only at the end did I add, Oh, and he is a diabetic. The look of disdain and offense and disgust that I was shot by Dr. Banks as he straightened himself up and snapped at me for only adding a crucial piece of “the case” as an afterthought. The look of glee from Lee Younger, one of my residents with a cruel streak, as he contemplated my dismemberment. I wasn't in Philadelphia anymore, I wasn't in a classroom anymore, I was no one in particular's son in the eyes of Dr. Benjamin Banks and Lee Younger, I was just an ill-prepared second year student at the med school that had just decided that waiting for the third year to send the students onto the wards was a waste of time, let's just send them in second year, ready or not here they come, and Dr. Benjamin Banks had probably been one of those in opposition and here was the proof of the pudding, ill-prepared me, fresh meat. Maybe thin-skinned me, entitled me, reluctant me, not ready for prime time me. I guess.

Weeks later in the rotation we made rounds on the semi-private rooms at the BI. Little groups of housestaff, short white coats, “Boys In White” was the title of a sociological study of medical school, senior residents and junior residents and interns and students on what seemed like a traveling team huddled together going from room to room, like a platoon. We visited patients, reviewed their tests and studies and vital signs and reviewed the chart notes and performed for one another. We were there most of the day while the attending physicians came and went. One lady was in her late 40's, I guess, petite and dark haired and wiry and very yellow and very concerned about something as she approached us to find out when something was going to happen or something, but almost frantic. The head of our team, maybe it was Bruce Chabner who went on to excel at the NIH, dealt with her formally but not unkindly, she scurried back to her bed, somewhat unsatisfied, and we moved on. That afternoon I guess we were going to go back to see her but we heard that she had died. She had been so alive. No one said anything.

I was sent by a chortling Lee Younger to evacuate manually the bowels of Mrs. Naruscewicz, who suffered from some apparently terminal illness, was bed-ridden, who couldn't speak English, and who objected to this necessary but invasive assault on her body with groans and grunts. I said, there there, I have to do this, and she resisted but I was finally successful. It was quite unpleasant, which pleased Younger no end.

Of all the Harvard hospitals I had chosen BI for my internal medicine because I had heard they were the most humanistic in their approach, a hospital with a heart. Maybe so. But it must have been there that I was introduced to the gallows humor of house staff, a psychological defense against the trials of dealing with people with serious diseases. Most memorable were the series of signs of the dying patient – the O Sign when the mouth of the patient formed that perfectly round letter, the Q Sign when the tongue protruded out of the edge of the mouth, and the Fly Sign when an actual fly buzzed round and round the patient's face awaiting death. I guess we laughed when we first heard it. It was there that I heard the expressed intellectual fascination with the pathophysiology of the patient, the distancing from the individual in anguish and distress, those feelings that went unremarked, or frowned upon as unseemly and uncontrolled. This was the foreign territory of clinical medicine I hadn't experienced at home, where my father suffered along with his patients, usually nonverbally. He never made fun of a patient, he never discussed a patient's physiology with relish, although he did manage to publish over 130 papers, even though he was not in a university hospital. He most relished the two bottles of wine he received each year from a patient who never forgot, and he would have relished the short speech of a person I didn't know, who came to his memorial service at The Quadrangle, his last home, when this man stood up at the front and told the story of how my Dad had made a diagnosis of his own dad that no one else could make, and operated on him, and gave him decades more of life. No one talked about things like that at the BI.

But of course my Dad had his own defenses. His telephone number was BA6-5050, which he said was appropriate, since when you came to him, that was about your odds, 50-50.

I also did my obstetrics rotation at the BI. I “delivered,” that is, I sat at the foot of the delivery table when a Catholic mother pushed out her eighth baby. I guess someone congratulated me at my first delivery. I don't even remember clamping the cord, but I certainly remember the other-worldly feeling of a newly formed baby, a little human being, coming out of another human being and landing in my lap. No one said much.

Finally, I did my pediatrics rotation at Children's Hospital. Since it was my last rotation I got the most out of it, I had been acculturated, I knew about coming in early, I knew how to present a case, I sat quietly and cooperatively with the neonatology team helping them do a double volume exchange transfusion of babies with Rh factor incompatibility, erythroblastosis fetalis, all that. One day I was taken into the neurology ward. All the little kids were on the floor playing with toys, little toy cars to pedal around, in their hospital clothes. And they all had football helmets on their heads. I wondered what that was all about, and either I figured it out or someone told me it was because on neurology, kids had seizures, and their heads had to be protected as they fell. It was shocking to me, these poor kids, the parents. But no one said anything.

There was one very nice attending there, an active, extroverted somewhat pudgy, bouncy, and kindly man, and I posed a question for him. Why are the internists such stuffed shirts, and pediatricians are so nice? He said, it's very hard to be a stuffed shirt when your patient is peeing on your leg. Question asked and answered. I went into pediatrics.

We were taught and questioned and quizzed and tested and coached and examined and rated on all our scientific and clinical knowledge and skills and performance. Our emotional reaction to all that we were exposed to and experienced remained, throughout my training as a medical student and later as house staff and as clinician treating thousands of patients through decades, as patients experienced severe illnesses and deaths, as well as wonderful cures, unexamined and unexplored, private territory to work out on our own.

Budd Shenkin

Medical Student Medical Event Debriefing Service - A Proposal

 

Medical Student Medical Event Debriefing Service

MSMEDS

Inevitably, in the course of medical school training, medical events will occur which are striking. Sometimes they are destabilizing – being present at a death, seeing a patient happy one minute and dead the next, seeing a patient raving crazy, seeing a patient and family receiving a dire diagnosis, seeing the controlled chaos around a code blue, tending to a severely ill patient day after day with no end in sight, seeing children suffer and families coming apart. Sometimes, happily, there are uplifting events – an amazing life-saving, life-changing event, a great diagnosis and treatment, an operation that seems magical, a recovery to health, seeing the devotion of a spouse, a birth. Whether positive or negative, seeing the human condition unfold before you, where you are a participant, where the context is medical, is a deeply emotional experience.

How do medical students deal with these experiences? Variably. All students are different, the circumstances in which they find themselves with each event are different, the input they get from those around them are different. Usually, most of what happens to students is internal, often solitary. They absorb it. Sometimes there is the counsel of a wise and experienced clinician, someone who handles it in their own way, who can give advice, someone who can offer concern and solace. Occasionally, such a person can elicit the students feelings and reactions in a way that not only consoles, but deepens their appreciation. But in most medical schools, I think, this is usually a matter of chance, of who is available when, of who has time and inclination, of who is equipped.

Sometimes, unfortunately, the surrounding atmosphere is not so positive, and reactions are psychological defenses. The gallows humor that develops in medical trainees has been well documented, as senior students and house staff ironically make light of a dying patient. Iconic sarcasm on medical lingo is typified by evocation of the progression from the O sign to the Q sign, and to the Fly sign. The O sign is when the dying patient's mouth forms a circle; the Q sign occurs when the tongue protrudes in the corner of the mouth, and finally the Fly sign is when a fly hovers circling the patient and awaits his or her death. House staff observes the process of dying by asking, how far along is he, and reference made to O, Q, and Fly. Sometimes there is just a flip comment, “That's the way it goes, on to the next.” House staff laugh as they assign the student to evacuating the bowels manually of a terminal patient. Often there is intellectualization as in, “What a fascinoma! Wasn't that an amazing EKG?” It's not so different from soldiers, or police, as they gird themselves against the rigors of their profession and life itself. Defenses against the stark realities of life, disease, and death abound.

You would think that medicine, with its history of beneficence, would have evolved ways of passing on wisdom in the face of these events, and in many ways it certainly has. But in many ways it hasn't. When airline pilots have traumatic events, accidents or near-misses, guidelines call for them to be grounded and counseled for a period of time. When that happens to a surgeon, he or she is expected to proceed to the next case as though nothing had happened, schedule comes first, tough it out. And students and trainees, when faced with these events, are often left to fend on their own. Scientific knowledge is presented and judged and tested constantly, but humanistic knowledge almost never.

If students are to be taught humanistic medicine, it would make sense to recognize the impact of these events, and to view them all as opportunities to deepen the humanity of the student, whatever the student's ultimate career objective. Students could profit enormously by discussing the events, and most importantly their reactions and their feelings and their reflections on the events, with someone wise and understanding and experienced. Doctors have a lot to give in their roles as physicians, but what they can give is predicated on what they have absorbed.

While departments and divisions throughout the university will have resources to provide this reflective counseling, and while there is something to be gained by having a variety of approaches that different disciplines might offer, some centralization would have advantages. A separate service would ensure that effort would not be diluted and derided by those who view humanization as somehow namby-pamby. A centralized service would allow faculty to best learn from each other, and to identify strengths. A centralized service could arrange for constant availability for processing events. A centralized service would bring more attention to the effort to all the students, perhaps even by conferences, classes, and publications. A centralized service would enable tracking of the student body to take place, papers to be written about the experience, statistics to be kept, and progress made in an organized fashion. If it's important, put it in one place, and staff it with those who are wedded to the task.

We propose, then that a MSMEDS be established. There are many ways that one can imagine that this service would be organized and operated. Wherever it is centered, the department of psychiatry should be involved. Senior clinicians noted for their humanity should be involved. Departments notoriously resistant to such considerations – one can think of orthopedics and urology, perhaps – should be involved. Students should be empowered to participate in the shaping of the efforts.

To support this important service, funding should be assured, and yearly reports should be made available on the efforts of MSMEDS. If it's important, give it money, give it personnel, and write about it.

Budd Shenkin