Integrity vs. Despair

 

I've been pretty unconscious about it. Since I've passed 80, unimaginably and contrary to all expectations – mine, anyway – and since my wife has passed on – unexpectedly, despite her long illness, I never expected her to die on me – since I've passed 80 and I'm living alone, although I have friends and family I retire to our house where I am alone with my computer and my television and my refrigerator and several bathrooms, I now proceed through each day with some idea of where I'm going, what tasks to accomplish every day, because I do insist on accomplishing something everyday of either urgent or long-term implications, even if it's just putting some stuff in order that I've been wanting to do, and I don't plan a lot of the rest of what I do. It just kind of happens, in a way, although it all seems purposeful.

So it seems I'm seeking my past and in a way stitching it together, not respecting time very much at all. I'm reaching back to the different parts of my past, the people in my past, and some of my past activities. My past activities seem to be centered on my pursuit of learning and my school days. I take French, study it each day, read French books and love it, I lie in my bed and read and underline and I study French on my computer and I write little notes like this, and I write a chapter of my French novel each week – up to chapter 286 this week. I love my characters in the novel. Who would have thought that that's what I would do?

And now I take advantage of my own and my contemporaries' longevity and the abolition of long-distance charges, reminding me how much of a curse AT&T was, years of high charges and stagnation. It's actually amazing. My past is studded with friends who still exist and who will still talk to me or write to me. My oldest friend is my brother Bobby whom I have known since I was 2 years 8 months old, although I don't remember when we met; according to me, he was just always there, a little bit smaller than me. Then there's Bob Levin, from kindergarten, John Raezer from nursery school originally, and then he was my high school friend where he was a God and then roommates in college and friends ever since. My high school friends, a bunch of them, Lynn Sherr whom I love to introduce as my friend for the last 65 years, Jonny Fish who lives nearby and Jon Gross from fifth through 8^th grade and then high school, and my med school friends, lots of them now, and Tom Uridel and Jim Perrin from the Public Health Service, and so many more contemporary friends from practice from the neighborhood from book club from our new friends in Maui and so much more.

It's like jewels on a belt of time that you can lie out flat and see the periods, and rub whichever jewel you want, or roll it up and then the different times are right beside each other.

They say that you take stock of yourself at my age.

Integrity vs. Despair – According to Erikson, the last psychosocial stage is Integrity vs. Despair. This stage includes, “a retrospective accounting of one's life to date; how much one embraces life as having been well lived, as opposed to regretting missed opportunities,” (Erikson, 1982, p. 112).

So you do, or at least so I do, but it's not as serious as all that, and it's not mournful – well, maybe a little – it's more grateful than that. It would be even better if I could revisit the women in my life – I wonder what happened to those women friends in Sweden, when I was so desirable but so confused, but also very fulfilled. I'd love to see them again. I really should go back there and visit Annika, although I'm lacking an invitation.

But what I wanted to mention was the conversation that I had a few days a with John Wesley, a friend from Leverett House in college and from med school. I called him out of the blue – why not? I have his number in my contact list and, as I said, calls are free these days, amazingly, and we have the equivalent of Dick Tracy's wristwatch radio, called a cell phone. I talked to one of my college roommates, Arthur Freeman, last week, he just up and called me, on Raezer's urging. We talked for an hour and 45 minutes, picking up where we left off, although it's been about 60 years. We had to catch up.

But in talking to Wesley, he reminisced about being a resident in surgery at the Mass General and his fellow resident was John Erdman, another friend from college and med school both, who committed suicide as a young doctor. There are various theories, I guess, and I don't know the facts, really. I did hear he plugged himself into an IV and infused something fatal as he lay on a gurney. But the story John told, with a humorous lilt in his voice, strangely, was how their chief resident demeaned John in front of all the assembled residents for not knowing some basic data, the hematocrit, of one of his patients. He said something about “Sweet baby Jesus” having a task for everyone and if everyone doesn't do it then it doesn't get done. A public putdown. John thought it was charming and funny, somehow. But I can imagine the emotion Erdman must have had, and the fact that he later did himself in, and I can't help but connect them, and I can't help but think of the inhumanity of the hospital setting for trainees, just when the tension is so great and the relief and support so needed. I remember the small provocations I experienced. I think of what my med school friend Larry Kadish just related last week in our Humanistic Medicine Initiative discussion, when he was serving a medicine rotation as a resident and a new patient was admitted from the ER and turned up on the ward dead. Here's the way Larry put it:

Although I had a surgical internship, every surgeon in our program had 2 months of medical rotation. My rotation in medicine started July 1st.  My first patient had an MI and was sent to the medical floor from the ER.  I examined him as soon as he arrived, but he was dead.  After informing the family, I called the second year resident to inform him.  He said I was lucky to have a Q-C.  I should go to bed.  A Q-C was a quick cool.  So much for humanistic values.

I guess that qualifies as taking stock of myself, or ourselves. I figure that our HMI, seeking to help students appreciate and solidify humanistic medical values and activities, is part of reassessment, taking account, and then doing what parents do when they lose a child, try to prevent others from suffering our fate if it can be avoided. Look back and repair, if not for yourself (time's arrow takes care of that), then for others. In our case, help the current students to at least understand the pressures they will be under to lose their humanity as they become professionals.

But it's not all grim, unless I dwell on my failures and embarrassments, which are so many. But I do have my strengths, which might be overrated, but it's pretty amazing how time has continued, and how I can make a claim to a successful life, even in terms of helping others, which I suspect of conventionality. But there it is.

I guess it's no sin to be conventional.

Budd Shenkin

Newsom Could Sharpen His Defense Of Biden's Age

I caught the last part of last night's Newsom-Desantis10-rounder, a worthy undercard for what's perhaps to come. I don't like these face-offs much, dispute for dispute's sake, don't stick to the question, no premium on clarity, and Hannity is a disgrace – tilted questions that weren't even disguised. But given the form, Newsom is formidable, and Desantis was persistent in his execrable opportunistic right-wing lying points.

But as strong and prepared as Newsom was, he could have done better on the Biden-age thing. Hannity and Desantis both harped on the “obvious truth” that Biden isn't what he used to be. Newsom replied that he has been a terrific President, getting so many things right. Which is true, but it isn't quite direct enough, to my mind. It doesn't spell it out. I spell it out in my post here, but here's a shorter reply that Newsom could have adopted, and that other Dems should adopt as the campaign progresses.

The best answer to that is this: right! Of course he isn't! We all change, for the good and for the bad, all the time, as long as we're alive.

But it's a balance. You get better at some things and worse at some things. As you get older, your numerical calculation skills decline – it's hard to divide and multiply in your head. But, you also get smarter with experience, you gain in wisdom, you've seen a lot more. When you're young you might have more energy – although Biden is still tremendously full of energy, just look at this schedule, what he's done around the world as well as at home! But when you're young, you don't know as much, you haven't been around the track as much, you are more impulsive, less patient, you have gained less wisdom.

Reagan was right in his debate with Mondale – he vowed not to make an issue of how untried and inexperienced Mondale was.

Who knows more about government and getting things done than Biden? Desantis? GMAFB. Who knows more world leaders over more years – an indispensable advantage in foreign affairs – than Biden? For that matter, who knows people all over the country, and understands them?

Yes, Biden's walk has become stiff; there is some arthritis, no doubt. He sometimes has trouble with words – but that's not new, and in the end, it doesn't matter. He's still sharp as a tack, he's still solid in his values, he knows how to be patient and go one step at a time, but he also knows how to act at the right moment, to be decisive, to be sharp and on point and seize the day. He still knows how to relate to people in and outside of the governing process, and that is indispensible.

On balance, he's better than he's ever been, and we're so lucky to have him.

Budd Shenkin

Muddling Through

 

Dear Reader:

Note use of the singular – you might be the only one. This post hides in plain sight. Potentially public, it will be very private, because if I don't tell anyone about it, here it will sit, you could say lonely, but that's not actually how I see it. I'd just say, unobserved and tranquil, like a book in a dusty library, with the pages uncut. Since I'm studying French, sometimes words come up that you would say in French, “tranquil” being one. Sometimes a word will pop up in Swedish, that language I learned so long ago but which stays in my mind, lurking, like a pleasant kind of shingles, welcomed outbreaks.

It's the end of the month, and I vowed I wouldn't let November creep away without a post. I've got so many planned, and a couple almost ready to go. Good ones, I think. I'll put out notice of them once I post, maybe next week. I plan some of my posts and work on them, and some I just wake up and write. What the mind does in bed, reposing (another French word, note), I don't know, but there's a clarity and a creativity, you just see it as it comes and then help it along. It's so funny that “work” would be defined as something we do awake, sitting or standing, alert, doing something. But the non-work of lying there is some of the best work we do.

I didn't know that when Ann died it would be so profound for me. Of course I should have known, but I didn't. Let's just say I'm not a planner, which makes my trip East in early October, a week in Boston and New York City, so amazing, because I had to plan everything, including the times that would be unplanned, and it all worked out perfectly, 100%. Each thing fell into place, even the train when I found myself sitting next to a companionable lady, whose name turned out to be Andrea Forbes, returning home after a sojourn (French word) with old Wellesley classmates, Tower Court, Class of 1981, and we talked for 3 hours. Even that turned out fine. I don't plan, it's hard to foresee things in detail, but you just kind of have to trust the future and your ability to cope. I get that distinction, by the way, from my time at the Graduate School of Public Policy at UC Berkeley, now the Goldman School, with initials unchanged, GSPP, when planning was juxtaposed to “muddling through,” as Lindblom put it. I'm a muddling-througher, so this whole period that they call grieving is such a surprise to me. I thought grieving was full of sadness, but that hasn't been my experience, it's more just readjustment. I think I haven't let myself think about it much, although now that I'm getting further away from it, I do let myself, and mostly I'm sad about the missed opportunities we had to be happy. We had lots of great times, it's true – if I think about them, I get sad. The good times make me sadder than the bad times, as you would expect, but not as I would expect because I don't expect anything because I'm not a planner. Still. I wish we had relaxed enough to love each other the way we did, we were devoted to each other, but there was conflict, and there was Ann's illness during the 80's and 90's until she got better with about 20 years left to live. The final illness, which took years of decline but when we were really, paradoxically, sometimes the happiest, well, that was a crescendo or decrescendo, or both, I don't know, but then for some stupid reason, I didn't know that when her death finally came, that it would be such a period for me. Period, as in comma and period, not epoch and period.  I discovered that part of the marriage vows should be, "I now make you the most important person in my life."

So, of course I knew it would be a big difference, I just had no idea how different it would be. It's not all bad, not at all. It took some getting used to, but I'm fine alone. That is, living alone, not being alone. I'm not in some woods with a clearing and a log cabin and no one around. I can talk to everyone; we have phones, and “long distance” is a thing of the past. I look to my past, and I have friends from virtually every period of my life. Bob Levin dates back to kindergarten, and now we live 2,500 miles away from the Henry C. Lea Elementary School, but we live about 3 miles apart. Bob says, we didn't like each other then, and I answer, well, I liked you. My high school classmates (a bunch of them! Including Lynn, who I saw in New York in my perfect trip in October), my college roommate, my med school classmates, two friend from the Public Health Service, Dean from my practice days (a closer and closer friend, Dean) and my basketball email friends, Rich my medical director from Bayside Medical Group days, Stu from Alta Bates, friends from GSPP, neighbors, friends from the gym, my sister-in-law Nancy, my kids, my brother and sisters, book group friends, friends from Maui and the Makena Surf. And I left people out. New friends who I walk with Saturday mornings at 6:45 AM, and then we have breakfast. And still, I have lots of time alone, and look forward to Tuesday and Thursday afternoons when Antonia and Jose come to take care of the house and garden, as they have for over 25 years, we're our own little family, they loved Ann so.

So, I didn't know what I'd do with my freedom. Would I “date?” No, doesn't seem to be in the cards, although I have a new friend I lunch with. I do notice that when I relate to women, it's with an immediate intimacy that takes them aback. They all respond, often with surprise, but with welcome. I was a pediatrician for 30 years, don't forget. They're not used to someone as emotionally intimate as I am. But, you know, I've had a lot of relationships in my life – when I was younger I was liked – and now I'm 82. So the intimacy isn't going to be sexual, as far as I can see. It's kind of a truncated intimacy, but there it is, insistent. I do like women. I really like the new women I've met, doing the HMS project, at a dinner party, etc. But I don't date. You never know what happens, you just kind of muddle through.

So what I'm doing with my freedom is working a lot. I write my blog, and people read it sometimes. I think I write pretty good. People think I'm smart – Bob Levin and I have discovered that we have differing ideals – he always wanted to be seen as “cool,” and I always wanted to be seen as “smart.” Also a good athlete. Bob thinks if I had stayed at Friends' Central I could have been all-league in basketball and a four letter man. I never thought of that. As much as you can achieve your goals, it seems that we have, Bob and I. I think he's cool (and I love his books, especially I Will Keep You Alive,) and he thinks I'm smart, and I think others view us that way, too.

So, I work. Completely unforeseeable, since Ann died of Alzheimer's and it was a long process, I discovered a lot in the process and I realized that I knew nothing about it, despite being a highly-educated and experienced doctor. So, I've thought that med students should be better exposed than I was to the “humanistic” side of medicine. Our Harvard Medical School class of 1967 had a Zoom meeting last January on Alzheimer's and I discovered a real community of classmates who were animated about the caring side of medicine, so we started a project, we found great student collaborators and faculty collaborators, and we're actually being successful in getting to projects to help students develop in Humanistic Medicine. I tell my collaborators, always be pessimistic, these things never work out, so if there are surprises, let them be pleasant ones. So far, that's what we're having, pleasant surprises. It helps when you give money or have the possibility of same, let's be clear, but I'm trying to offer ourselves and our experience, and that seems to be holding sway so far. We'll see.

I'm working on my French, which I started before Ann died, and I've stepped it up. My reading is a lot improved and I've read about 30 books, I guess, all fiction, and I've been swept away by literature, French literature. I fell in love with Annie Ernaux. Read The Years first. One of her books is about the death of her mother. I read A Very Easy Death (which I took to be an ironic title) by Simone de Beauvoir. Writers and the death of their mothers seems to be a genre. Annie and Simone both turned those intimate deaths into literature. I had thought about taking notes as Ann declined and died – I did that when I had my macroadenoma of the pituitary and it's a great post – but I decided I wasn't going to do that. It would have been a service for others, but I declined. Nope, it was just going to be me and Ann, no prostitution. Not that Annie and Simone prostituted their mothers' deaths by writing about them, pas du tout, but it wasn't what I was going to do. But I loved both Annie's and Simone's books. I want to write a post about them, especially Simone's, but I'm pretty busy. I can't tell you how much I loved them. I'm so happy I can read the in French (with the English on my Kindle for reference.)

I'm also writing a post about the problem with primary care medicine in the US, which they say is dying. It will be a good post; it's close to done. Posts can be done without all the crap you have to do for a formal article; what a pleasure. Of course, in my case, hardly anyone reads them, but c'est la vie.

I've got to get all the pictures I've taken, and the pictures we have of our ancestors with little notes on who they were – I don't know but my sister Kathy might – I wish there were someone to just set me up doing it. It's the setup that's hard; after you know what the mechanics are, you can just find the time to do it. It's getting started that's hard. And now my damn desktop has lost it's internet connection, and the urgent will take precedence over the important.

I can't tell you how rewarding this project with HMS has been. I found this student who wants to be a leader and has all the potential to be, and I think I can help her. All my classmates are enthusiastic, and I think I can help them find fulfillment. I was telling Eana, the HMS student leader, that it's true, that when you give to others so often you are doing more for yourself than you are for them, even though you'd have to look way inside to find that out. But then, does that mean that when you are doing for others, you are committing a selfish act? Everything is so confounding in life. “Confounding” is a great French word.

In the spring of 2022 there was a class reunion at HMS and I found I couldn't go. I couldn't even write the class note on where I was or what I was doing. I didn't say “I'm not ready,” I didn't think of it that way, it wasn't that I thought I was sad, I just wasn't ready, and of course there was COVID, and I didn't think “ready,” really, I just thought I would be unhappy going, without Ann, even though she made things harder because of things she didn't want to do, and I couldn't be gone from her for too long, etc. But we had found a restaurant on Beacon Hill for breakfast, we walked there a couple of mornings though the Public Garden from the Four Seasons, and somehow going to the reunion and not walking over there with her wasn't something I wanted to do. So I didn't go. They had a good time there, and it was after that that my classmates started the Zoom meetings.

But then this last June there was a French students' trip to a chateau just north of Toulouse with my French teacher, and I did that, and then my sister Emily came over from London and we spent four days or so together and had a great time going down to Carcassonne, and then to Lagrasse and Perpignon and Barcelona and then we flew out, and I said, yes, I can do it, it was a perfect trip. Somewhere in there, near to a year and a half after Ann died, maybe a year and a quarter, I got up one morning and felt better. I hadn't felt sad, or maybe I wouldn't let myself, I thought about it I guess, but then I refused to think about it, as I said, but then I discovered that I looked forward to the day more, and then I discovered I could travel, even if I didn't have a built-in companion to travel with, and now I'm on Maui and I'm typing away and I have too many projects to finish, but somehow maybe I will, maybe I'll muddle through.

Budd Shenkin

My Father Was Left To Cope On His Own

My father was a neurosurgeon, which I always thought was a defining characteristic. He was dominant. He was also loving and supportive, at least to me, and he treated my mother basically as an equal, or nearly so. They had a traditional marriage, and Dad said of her, she always supported me. When she died at 72 of breast cancer, they had already moved to a senior living facility, the Quadrangle near Haverford College on the Main Line in Philadelphia, because my father got nervous, worried that if my Mom died first, he would find it very difficult to live on his own. Impossible, really. When I suggested once that he make lunch for himself, he growled at me. “I've never made my own lunch and I'm not going to start now.” Or maybe he was nervous that his house in center city Philadelphia would lose value – Dad could never hold onto assets.

He lost my Mom and I didn't understand what would happen, and I didn't worry about it. As my Dad would say, caring goes down and it doesn't come back up. I did care about him, but I didn't take care of him much. I figured it was up to him to take care of himself, and that he would. I didn't worry about him. I didn't think about what it would be like for him to have an apartment where he lived alone. Of my kids, it would probably be the youngest, Peter, who would be most conscious of his father's plight. The others are more like me. I wasn't in Peter's class when it came to caring.

So in maybe less than a month after my Mom died, my Dad had hooked up with an old friend, Reva, the divorced wife of a doctor friend, Richard, an orthopedist. I had met their son years ago, a boy whose son's lips were always blue from Tetralogy of Fallot. He had died in early adulthood of failed heart surgery. I had never experienced compassion for this blue-lipped boy, just as I hadn't experienced compassion for the boy in my high school class who was frequently absent from school because of kidney disease, who died in adolescence. Actually, truthfully, I thought I was lucky not to have known either of these boys well, because then I didn't have to confront their death and my feelings about the death of a friend.

My Dad called me, as I'm sure he did to my brother and sister, to tell me about Reva and I said fine, that's good, kind of amazed at his speed, and he queried me about if it was too soon, meaning was it disrespectful of my Mom, and I said no, and he was relieved.

Richard, Reva's ex-husband, had actually operated successfully on my deformed right foot when I was in tenth grade. My father and Reva got along well, he was proud of her artistic prowess and she painted quite a nice portrait of him. He was also proud that she knew enough about art to buy the right pictures and make money on them. She was a real expert. They stayed together for maybe 10 years until she died. Her gynecologist missed a diagnosis of cancer when she had some bleeding, finding out the true diagnosis late, but I don't know if it would have made a difference. I didn't worry about my Dad's being alone, again, and I can't tell you why. I was busy, I had my own work and my own family. I was attentive, I called, but he was back to taking care of himself.

Even though he had a very nice relationship with Reva, it seemed like it was my Mom who he missed. My Dad would be hot sometime, there was a little shunt his mind would take and he would be hot, his emotions would take him away. So I remember once when he was in a mood, feeling lonely I guess, and he said about my Mom, “She had no right to die! She had no right!” Of course he knew that that was ridiculous, but that's the only way he could express himself.

She had no right to die and leave him alone. He didn't worry about sounding ridiculous with me, he said what was on his mind. If something goes wrong, find out who is guilty and throw the blame their way. Everyone has to have a way to handle setbacks, and this was his. Took me a while to get my own way to react, I naturally followed the family tradition, but I found that my kids tend to laugh at something that happens to them, and I've kind of picked it up.

But then with both my Mom and Reva dead, there he was alone in his apartment. I didn't think that much about it, although I was attentive, and he didn't want me to worry about him, either. He just wanted me to stay in touch and to visit when I could. He had his friends around the Quadrangle, and they seemed to take care of each other. Meals were in the dining room, and Dad had his regular tablemates. A nice man named Steve, and his wife, and then a woman named Anne who attached herself to him. That's what happens in these places. You trade independence for company and security. Anne adopted him as hers, told everyone that he was the love of her life, she was kind of weird, a lawyer who had practiced in Texas, I think, but her family was local, and I have pictures of Dad with Anne and her family for holidays at her daughter's house, where he looked jolly, which I found strange. He adapted well to being adopted, I thought. He was her man-friend, or something. Dad tried to tell us her good points, her achievements about being the first woman to be counsel of a company or something, the way he had praised Reva's art prowess, but my brother hated her, and I tolerated her and was polite if not very warm and of course, Dad needed her and was lucky to have someone.

As I look back on it, I thought he had lost all his neurosurgical power – well, that's not true. He had his prestige, he had his past, he had the dignity of his achievements and his former stature, some of which still applied. But do you really need that when you approach 90 and you're in a big institution where you've been for close to 15 years and you've seen them come and go, and when you walk to your meals down long hallways, or drive your cart as time went on instead of walking and where some busybody complains that you drive too fast, and you drive past the little shelf off to one side where the latest deaths are announced in little white cards and the day and time of the upcoming service, and when you go up to the nursing home part of the Quadrangle and you see the debris of wheelchairs with slumped occupants and maybe a TV on and you see that you never want to be like that – do you really need your past stature? You're in the long corridors of the Quadrangle, driving toward the end, and you're lucky if you have someone to keep visiting you in those last days when you need constant attention and when you can no longer hardly get up to go to the bathroom and you can't wipe yourself and who cares about stature then? That's when you pull yourself together and tell the doctor you want to stop taking the pills that keep you alive, you just want to keep taking the pills that make you comfortable, and I'm not sure what you think about, but Steve and his wife and Anne visited in the days, and when one of your four children is there every weekend, and then your California son comes in Friday night on your last weekend and it's like you've been waiting for him, and he brings you a little video player and he puts in a CD of your favorite movie, The Producers, and your oxygen level must be low by this point but you see the movie and you recognize it and you point to it and you look around to see if the others are seeing it, too, and you make sure they do, but then you relax back down on your pillow and everyone goes home for the night and Buddy and Bobby and Susan go out to dinner and Bobby says I've never seen him this bad, and he's right because they discover him in bed dead about 6 AM or so, as though he had been waiting for me to come.

And I wonder if he thought of my Mom, or if he thought of anything really, that night before he died. He was dead when I sat in his room after Bobby had called me to tell me he was dead, and everyone else cleared out and I sat and I cried so hard, and I called him Daddy, and I knew I loved him so much, and I think he knew it, too, but one way or the other, I was there in time, and I brought him a present that he loved in time, and one of the last words he had said, I'm not sure when, was “92,” which was how long he lasted, to 92, and who'd a thunk it, he seemed to say, his last achievement, lasting that long. An achiever to the end. And as far as I know, he never had to make that goddamn sandwich for lunch on his own, his contract called for three meals a day and he was having three meals a day, or at least two, and he was being taken care of in that infirmary until the very end full service because he had been an original resident and that's what his contract called for, back when they were offering good terms to attract people to get things started, and Dad made sure that he was going to get one of those good contracts for being an original resident, and God help them if they tried to charge him. And some old friends, or at least acquaintances from his former life would themselves move to the Quadrangle and see that he was already established there, and he took care of himself, more or less, until close to the end. Or rather close to his end, not the end, because the world goes on and nobody is irreplaceable, they say, although I don't believe that. My Mom was irreplaceable for my Dad, although he did replace her, but not really, because he had had her when they were young, and when their kids were born, and when they traveled together, and when they were amazed and delighted at their successes and the life they had built so far above where they had been born, and they would remember that together, and only they could do that, no replacements allowed for that.

And no replacement allowed for my Dad, either. No one ever loves you like your parents, I think, but maybe that's overgeneralizing. Some marriages are really so strong, and good on them.

In retrospect, I regret that I never thanked my parents enough, for all they did for me. I did tell them I loved them, which was good, but I didn't thank them. I didn't thank my wife enough either. I should have thanked them more. But at least I told them I loved them, and for all of them, I was a good boy. I did get to take care of my wife, to walk the walk, but not my parents. But my Dad took care of my Mom until she died, she didn't need me. And for someone who couldn't make himself a sandwich, Dad did pretty well for himself.

I did what I could, I was attentive, and I told them I loved them. Thank God I did that.

The Terror of Medicine

 

I think it was starting this new book – new to me, anyway, used edition, 1984 – L'Amant (The Lover) by Marguerite Duras, that got me started thinking about this thing I have successfully repressed for a long time. That, and our Class of 1967 Harvard Medical School project on Humanistic Medicine. I'm only a few pages into it, but it's a book of images and interiors, a French high school girl in colonial Saigon, with two brothers, a father who is going to die, and a mother who it seems won't last much longer, a mother who is distracted and ineffably sad as she tries to cope. At the same time I'm hearing from my med school classmates about their own coping with the medical care system as we age and our medical needs increase, how some of us are well served and others aren't. And how everyone is coping with the choice to move to a facility for older people or keep on going as we are.

But all of a sudden, as I was reading L'Amant in the bed that my late wife and I shared for years – I slept there last night for the first time in a long time, I've been staying in the attractive front bedroom in the house were I slept when Ann had to sleep alone in our bedroom and be attended our health aides – all of a sudden, the image came to me of my patient Ms. Ratto, I forget her first name, but Ratto is a common name in Oakland and Alameda, there's Ratto's Delicatessen around 8^th and Washington in downtown Oakland, and there's Ray Ratto, the local sportswriter turned TV, radio, and podcast analyst and raconteur, known for sardonic humor, whose family became my patients when we opened our Alameda office and he and his wife showed up for a prenatal visit and when I heard he was a sportswriter for The Examiner, I told him I was thrilled to meet him, and he told me I'd get over it. Anyway, this Ms. Ratto, a fair-skinned red-haired-to-auburn, very sweet mother of two, was my patient, and they claimed not to be at all related to any of the other Ratto's that I was familiar with. Right. Somewhere along the line, somebody didn't want to be known to be related to somebody else, I guessed.

So I had the image of her face in my mind, in our Alameda office, an old-fashioned office that took the whole second floor of a two story building that could have been an old house, that we rented from the dentist who occupied the first floor. She was distracted, too, like the mother of the narrator of L'Amante.

What do you do when you are dying of breast cancer and you have two little kids? Thank goodness you have a good husband. But, she looked at me full in the face – I still have tears when I recount this – she was still apparently healthy to look at her, hadn't yet lost her looks or her energy, it looked like, but she said to me, straight-on – what is going to happen to my kids?

Oh, how I wanted to help her. I wanted to take her in my arms and hug her and cradle her and tell her something and do something and make things all right. I could have tried. I could have said that her husband was a good guy and he'll find someone to be a good mother to them, which was probably true. I could have at least said I would be a good and loving pediatrician for them. I could have cried with her, making things worse, no doubt. I wanted to do something. I should have been able to do something, shouldn't I have? I was their pediatrician, and I cared for her and them, and they cared for me, too. It was everything that a medical relationship should be.

But I was helpless. I could have told her how much I wanted to do for her, but I had no idea, and I still don't, of what I could do. What do you do when there is nothing to be done?

I don't recall seeing her again. I must have seen the kids, I don't know, I just don't know. All I know is that it was searing. What do you do when there is nothing to be done? I could have asked her what she was doing, what could she conceive of doing that would give them the best chance ever. True belief in religion used to help with this, the Lord will provide, and sometimes I tell myself that now, knowing that I don't believe in God, but it's a great heuristic, an as-if.

I bet there are people around, in the medical schools and in practice, both, who know a lot more about what I could have done, what the medical system or the social care system could have done. It was probably up to the family, her husband, the grandparents, the aunts and uncles, everyone, to pitch in. I didn't know. But that's not what she was about. We had a relationship, she and me, patient and doctor. She could bear her soul to me. I could listen and accept her projection of what she wanted me to be, as her pediatrician. The way a pastor must feel when parishioners turn to him or her, what do you want me to be. She just wanted to tell me her deepest thought, wish, fear, terror. What will happen to my kids?

If I had known what I was doing, I would have found the time to sit with her, and listen, and reassure. Share her feeling. Then I would have been a good doctor. Avuncular, paternal, something. Helpful. Maybe I did

But I didn't know. I don't know, maybe I did do something good. Maybe I actually reassured her, although I don't remember that. Really, I was in the shock of being confronted by life in all its terrors. Talk about not being prepared. The fact that tears come to my eyes now tells me that I wasn't prepared for that. Maybe I had heard a rumor about her condition, maybe from another patient – so many of them knew each other in Alameda, although apparently not the various Ratto's – or maybe from one of my staff members. The best medical offices have staff and professionals who share a mission, and help each other to cope and do good. But whatever it was, I was still in shock. Face to face. Terror.

I'm just into the first few pages of this book. I don't know what happens to this girl. I don't know how autobiographical it is. I have intentionally not read too much about it, I want to confront it face to face. I just read my sixth Annie Ernaux book, Se Perdre (Getting Lost), and the shock of vivid and consuming autofiction (I doubt there's much fiction in it, really, maybe some compression of facts, and as in all non-fiction, the choosing of facts to fit a narrative) is still reverberating.

Life, literature, reading and writing, medicine, helping people, being helpless, the unrelenting pace of events that won't stop, time stops for no one, the earth is 4.5 billion years old and our universe is apparently 13.7 billion years old, but this is what we have, the here and now, the present, the awful unrelenting present from which we try to extract happiness, love, support, the illusion of eternity here in the present.

But at least, I hope that our Humanistic Medicine Initiative from our HMS Class of 1967 helps some of the present students and trainees, the age of our grandchildren perhaps, at least what little we can do will help some of them to cope and help with their mission of being physicians, and helping people with the burden of life.

Budd Shenkin

Doctors, Patients, and Hitters

As I think you all know, I believe that there are very few situations in life, if any, that don't lend themselves to elucidation by referring to sports.

Take my current project, where a group of my classmates of the Class of 1967 at Harvard Medical School have started a Humanistic Medicine Initiative, to try to help the current students and trainees develop their knowledge and skill in the caring side of medicine (“caring,” as opposed to the “scientific” side.) Part of this is, how do we help them learn to communicate effectively with patients? I heard that the Kaiser system, which tries to attack every problem systematically, has been teaching a standardized system of communication to its new clinicians. For instance, how long do you wait before you jump into a patient's recitation of his or her story? The usual wait is somewhere under 10 seconds, I think, and Kaiser wants to up that to 40 seconds. Then they have standard ways to start, words to use. Will they succeed in this standardized approach? Maybe so, because maybe the level of current communication is so low there is no where to go but up.

Somewhat akin to that is the recent finding that patients like the empathy of AI better than they like the empathy of real doctors really communicating on their own.

I ran across a more intriguing and sophisticated effort than those, or at least one aiming at a higher level result, in a JAMA article that I put away to save, but which I now (typically) cannot find. I think this was about how to deliver bad news or regret, and how to do it with empathy. As it happens, the author of the article was a resident in medicine doing the learning, and his father was a specialist in medical communications. So the author was going to show his father how he had learned to do it. Piece of cake, he thought – I've been watching my father do this my whole life! I know this gig!

So he does it, he follows all the rules he has learned from watching his father, all the examples he has seen. Then he turns to his father and says, well, how did I do? He naturally expects an A.

Terrible, says the father.

What? Why? I did everything that you do!

That's the problem, says the father, you did me. Now you have to learn to do you.

Crushed, the son has learned that it's not so easy, because we are humans, we are all different, and we all have our own way.

I don't remember how the article went on from there – I'll know when I finally find it – but the point was clear, and it makes intuitive sense. Well done, well written.

So, as I said, there is always a sports analogy to be found. There will always be a way to illuminate the point through sports. I searched my mind, and what came to mind was hitting. There are many great hitters, and they share some characteristics in their swings, but they are all so different! You can watch a swing with the hitter being otherwise unidentifiable – no number or name on the back, no face to recognize -- and some of them you can get immediately right on the nose, and some you can make a good guess at, and there can be such a wild variety of swings, but some you can classify as good, some as bad, so can tell that some of them come from the same hitting coach (does the name Charley Lau ring a bell) and so resemble each other – but I guarantee you, every single one is different.

And it's such a stereotypic task! It's amazing that there is such a variety of approaches! The best hitters share some characteristics -- there are the basics -- and many bad hitters share the same weaknesses, but none are quite the same.  And some will work for some people, and others will work for others, they can learn from each other, there are certain basics, but each one must fit the individuality of the batter.

And, I would add, some work best with some pitchers, and some work best with others. It's a combination. Some patients need one thing, some patients need another, and there are some hitters who can hit some pitchers, and others can hit others, etc., pairs of pitchers and batters that work and some that don't.

And then, think of how many different ways there are of shooting a basketball!

I won't go on, because either I've made my point or I haven't, you accept it now or you don't. Just like some people like what I write and others don't.

But to me, I made my point. Which is that sports is not just pointless games, but in fact, they encapsulate life, one way or another.

Which is a point to rebut my father, long gone now, but still I work to both please and rebut him – Dad, sports are not just a worthless waste of time! Sports are life itself!

Budd Shenkin

Biden's Age -- Gift Or Burden?

 

It is a well known but still amazing fact that our President is now 80 years old, and that he is running for a second term and would be 86 at the end of that term. Alarm bells have sounded, many smell disaster ahead. After all, they say, they know what “old men” are like.

But do they, really?  They refer to the stereotype of an “old man” who dodders with frail body, weak memory, decreased reasoning power, depleted energy, inflexible ideas, no capacity to appreciate the new or the young, and liable to be injured or simply collapse at any time. Or, worse, the old man might decline progressively and not leave office, allowing aides to prop him up and take over, or to let the country drift as he himself drifts away, as happened with Woodrow Wilson. Imagine if he should be replaced by a distrusted Vice-President. It's a nightmare scenario.

But think for a moment – does this nightmare scenario ring true with Biden, or is it simply an ageist trope? Here's an alternative: replace the term “old man” with “seasoned leader.” Modern medicine has increased healthy life spans; some say that 80 really can be the new 65. Seasoned leaders resist the impulses of the moment; their hard-won judgement allows them the patience to weigh alternatives and possible consequences, to appreciate ebb and flow, to know which moment to seize, to judge well. Their years have earned them wisdom.

The seasoned leader knows people at home and abroad, who to trust and rely on, and who to be wary of. They know how their chosen field works, because they have been at it a long time. With their perspective, they can actually be more forward looking than younger leaders, and more conscious of their potential legacy. Despite accusations to the contrary, older people tend to relate well to the young. Think of the warm and close ties of doting grandparents as they advocate and indulge their grandchildren, making sure the younger generation has good education and a healthy planet and are fair to one another. In fact, one has to think – wouldn't a grandparent sometimes make a better, more selfless President than a young, ambitious parent? Think “greatness of spirit,” not “old and broken.” Think secure and wise.

As Ronald Reagan put it in 1984, “I will not make age an issue in this campaign. I'm not going to exploit, for political purposes, my opponent's youth and inexperience.... I think it was Seneca but it might have been Cicero who said, if it were not for the elders correcting the mistakes of the young, we would have no state.”

Perhaps it is not President Biden who is stuck in the past, but the critics who cling to out of date stereotypes.

 

II.

But, to be fair, bad things do sometimes happen to older people. Woodrow Wilson had a devastating stroke at age 63 (old then,) and his wife and aides hid it from the country, while taking the presidential reins in their own hands. Dwight Eisenhower had a serious heart attack at age 65 (old then) from which he recovered in a weakened state. Ronald Reagan may have slipped into Alzheimer's in his 70's (old then) in his second term. Older people are at higher risk for serious illness, although the risk to the young is not insignificant. Think Kennedy. The risks might rise with age, but they are always there.

Since disabilities can occur to anyone at any time, it is important to be able to detect problems early, and to have back up capacities. Recognizing part of the problem after the Kennedy assassination, the 25^th Amendment was ratified in 1967, providing a procedure for replacing an ailing President, whether he or she recognize it themselves, or whether it is the decision of the Vice President and a majority of the Cabinet. But beyond that, we have no formal institutional guard rails. Informally, staff and close friends and advisors function as teammates, supporting and supplementing. But for early detection and remediation, more is clearly needed for all Presidents, not just older ones.

III.

Nikki Haley and others have suggested that a presidential candidate 75 years or older should be tested for mental capability to function in the office. Screening for capability to fill one of the world's most important offices might not be a bad idea. We in medicine know that some patients are more at risk of certain conditions than other patients, and we screen for those conditions to ensure early detection and treatment. We know that the concept of “average” can be deceptive – just because you have a higher risk of having a condition doesn't mean you have it. An 80 year old might be healthier than a 60 year old; a 60 year old may demonstrate more mature judgement than an 80 year old. In medicine we don't confuse risk with actuality, we know we have to evaluate the individual.

But here's the problem with Haley's suggestion – it's far too narrow. What conditions could compromise a candidate's performance as President? Surely it's not simply dementia. Other common debilitating conditions are: alcoholism, depression, anxiety, sleep deprivation, delusions, sociopathy, sexual deprivation or perversion, chronic anger. Indeed, a candidate might be quite literally crazy.

What about other conditions that could compromise performance? What about general intelligence? What about work habits? What about honesty? What about ties to foreign powers? What about temperament? What about prejudice? What about the ability to think through problems? What about the ability to build a team, a breadth of knowledge, a tendency to make a country more peaceful rather than more contentious? What about knowledge of government operations? What about executive experience?

These are all serious questions, and most of them are not age-related. That indicates that focusing on Biden's age is really a question of ageism. Yes, being older brings on the risks and characteristics of age, which can cut both ways. But to focus on just “being older” is unreasonable.

IV.

So what is to be done? A general health examination including the mental status of candidates would be a good idea, with the results released to the public. Just as the American Bar Association judges Federal judicial candidates as “qualified” or “not qualified,” the American Medical Association could be asked to issue a medical judgement on Presidential candidates. The extent of the medical characterization of the candidate's health would have to be determined. Do we want professionals to issue a judgement on alcohol use, anger management, sleep habits, fitness, paranoia? Or should we leave the status quo alone, with issues known to insiders leaking here and there in the press? Maybe we should leave it at blood test results, the clock drawing test, and short term memory assessment.

In the end, the political system must find its way to judge. In the old days of strong parties and leadership by insiders, the guard rails of protection of the republic were left in those quiet insider hands. Nowadays, when primaries have taken the place of smoky back rooms, more public information is necessary. But beyond that, we cannot now say. We will find our way to how much information is needed as we move step by step.

But for the present, it's best to understand that judging on age pure and simple is foolish. The characteristics associated with age are distributed on a Gaussian curve, and only individual characterizations matter. Claiming that a candidate is “too old” or “too young” or “too fat” or “too female” or “too anything” is not clear thinking. Over 80 and doing a good job vs. under 80 and corrupt and paranoid, you're going to rule out the over 80 as “too old?” Older age and well-tested vs. younger and untested Senator or Governor, choosing the younger on basis solely of age? Does that make any sense? This 81year old, exactly one year older than Joe Biden, says “Hell, no!”

Budd Shenkin

Thanks once again to David Levine for suggestions, including especially the final sentence!

PS – striking recent references:

1. Tom Friedman cites Biden's “wisdom:”

https://www.nytimes.com/2023/09/23/opinion/biden-netanyahu-meeting.html

2. Retired Three Star General James Dubik, quoted in Atlantic article on Mark Milley, decries Donald Trump's “cognitive unfitness and moral derangement.” Besides documenting the manifest unfitness of Trump, the article describes the ways in which the executive team and the military were able to erect guardrails through much of Trump's term in office, illustrating how supplementary influence of the organization around the President can be corrective: 

https://www.theatlantic.com/magazine/archive/2023/11/general-mark-milley-trump-coup/675375/