Saturday, November 18, 2017

Retirement, French, and the Horn

Men of a certain age wonder what to do when they are free – that is, when they are retired, not divorced. Some of us seem to know what we will do with our freedom, but others just need to discover it as that time rolls in.

My friend and fellow pediatrician Larry Hammer and I were comparing notes last Wednesday at lunch. I sold my practice on December 31, 2012. Larry is down to two days a week practice now, which counts as nearly retired. It seems we are both discoverers, and it seems we are both discovering things we used to do and now have time to do. For me, it's a melange of things, including writing – you, dear reader, are experiencing that right now, see how the words zing off the page! – and studying French, which I studied for two years of high school and one semester of college, and which was then superseded by Spanish and Swedish, both of which sometimes invade my French space as I seek to express myself with my new French teacher over near Piedmont Avenue. And I also work out several days a week. Time well spent.  But I make sure I do French every day.

What Larry is discovering seems to be his horn. When I met Larry a few years ago, he told me he visits the New Orleans Jazz Festival every year, and visits Yoshi's locally as well. He told me last Wednesday that, as his work time was winding down, he thought of getting out his old clarinet. I played clarinet briefly in my youth, so I could easily see the attraction. Then he decided to migrate to the sax. Again, I saw the attraction, as anyone would who likes 50's and 60's rock and roll. It's a great discovery for him. I could see the light in his eyes.

We both are going back to things we didn't have time to perfect, with no great expectations other than enjoying ourselves, polishing and advancing skills for their own sake. Along with going to ballgames, which we both do.

His turning to the saxophone had me remembering another pediatrician in the East Bay, Bobby Mines, like me originally from Philadelphia, and like me a long time pediatrician here in Oakland. Bobby and his former partner, Bill Jenkins, cared for thousands and thousands of needy patients in their high volume offices, working long and hard hours, and doing a great job with high quality. Bobby retired a couple of years before I did, and I asked him if he had any plans. 

"Well," he said, "I think I'm going to go back to playing the saxophone."

“That sounds like a good idea,” I said, “You used to play it?”

“Yeah,” said Bobby. “But I had to give it up for med school.”

“How's that?” I said.

He said, “Well, I was playing it pretty well, and I thought I'd like to continue with it. I was with a group, and we were doing a little touring, and I wanted to go along with that.”

“So what happened?” I asked.

“Well, my father told me that of course I could do what I wanted. If I went to Meharry for med school, where I was accepted, he would foot the bill. But if I went off touring, well, then I was on my own. I really loved my saxophone and my group, but you know, music is a funny business, so in the end I took his advice and his money and I went to Meharry.”

“I guess we all have to give something up,” I said. “But then how did the group do?”

“They did pretty well,” said Bobby.

“Really,” I said. “Who were you playing with, back in Philly? Who was the group?”

Bobby said, “I was playing with John Coltrane.”

“Oh,” I said. 

No, what I actually said was, "JOHN COLTRANE!!?"

I guess his horn is better than my French.

Budd Shenkin

Saturday, November 11, 2017

Weaponizing the EHR

I have opined before, and I will doubtless opine again, about the importance of the patient and all providers having full and free access to the patient's electronic health record, the EHR, with the patient's assent, of course.  Another article has now appeared, in JAMA, proposing a technical way that this could be accomplished:

The best way to effect record sharing, the article says, is to acknowledge that the record belongs to the patient, and for there to be entities called "health data managers," which would aggregate the data and distribute it. The article deals with the technicalities of how that should be done.

This is good work, but there will be many more problems getting there than the authors indicate.  They probably know this, but to speak to the political-business problems would be too much of a diversion for a short article.

But you and I have no such inhibitions.  Here's the letter I submitted to JAMA that speaks to the problems.  I just love my term, the WEAPONIZED EHR.  Doesn't that have a real ring to it?

The shared medical record was first advocated in theory in 1973, its practical desirability demonstrated in 2014, and now Mikk et al. have offered excellent and imaginative suggestions to enable widespread implementation.123

They underestimate, however, with their mild words “competitive advantage,” the opposition their reasonable proposals will face. Seeking business dominance by patient and clinician capture, the large medical centers and enterprise level software manufacturers have essentially weaponized the EHR by keeping it private and unsharable. When patient information is available only within an EHR network, the patient is “nudged” to access only in-network providers and facilities.4 Likewise, the externally impenetrable EHR pressures clinicians to renounce their independence and join the network not only to defray EHR costs, but also to achieve “featured” status for referrals on the EHR as the networks “nudge” referrals inward, and to utilize data in treating patients that they would have only laborious access to otherwise.

Maintaining strong EHR boundaries for network commercial advantage is regrettable. If large networks are to achieve dominance, they should do so by lowering costs and raising quality, which has been difficult for them, rather than using the EHR as a cudgel.5 Closed networks and closed EHRs provide diminished incentives to improve efficiency and quality, as services need to be just “good enough” rather than truly excellent to attract captured patients. A closed system even presents an ethical problem, since the primary care provider, who is ethically bound as a medical fiduciary to seek the best and most efficient referral resource for the patient, is nudged by the system to respect instead the financial needs of the network.

Even high-minded networks will feel forced to isolate their EHRs if “everyone else” is doing it. Government needs to help them do the right thing by setting EHR ground rules for business competition that redound to the benefit of the public. Public policy should thus mandate the authors' proposals so that patients have full and free access to their records. In addition, EHRs should be fully interoperable as soon as possible, choice of referral resources should be on a level playing field, and in-network and out-of-network practices should have equal financial access to EHRs. The EHR should promote full and fair competition rather than impede it. Clearly, it is political and economic forces rather than technical difficulties that are the barrier.

1 Shenkin BN, Warner DC: Giving the Patient His Medical Record: A Proposal to Improve the System. NEJM 1973;289:688-692.
2 Walker J, et al. The Road toward Fully Transparent Medical Records. NEJM 2014;370:6-8
3 Mikk KA, Sleeper HA, Topol EJ. The Pathway to Patient Data Ownership and Better Health. JAMA. 2017;318:1433-1434.
4 Thaler RH, Sunstein CR. Nudge: Improving Decisions About Health, Wealth, and Happiness. New Haven: Yale University Press; 2008.
5 Berenson RA: A Physician’s Perspective on Vertical Integration. Health Affairs 2017;36:1585-1590.

OK, all well and good.  But let's get to the personal side of it.  Me.

You all know the thrill of discovery, which is what I experienced when I saw patient and clinician capture being practiced by these large institutions.  I knew, however, deep down, that I couldn't be the only one to see this, particularly since I don't follow the EHR literature at all.  And sure enough, last week I ran into a guy who knows a lot more about this than I do, Richard Frank, who is professor at the Department of Health Care Policy at Harvard Medical School.  I shared my discovery with him.  He was very nice and kind as he told me, oh yes, we call that "information blocking," and I served on a board for the ONC (Office of the National Coordinator for Health Information Technology) that reported on that.  Here's the report:

So, there it is.  Citing "anecdotal evidence," the report says: "A common charge is that some hospitals or health systems engage in information blocking to control referrals and enhance their market dominance."  And, "the developer and provider may implement this capability so as to restrict the exchange of information to physicians who are members of the provider’s care network."  

So, there it is, what I am so impassioned about is, well, well-known and well-recognized.  My letter will not be published, and I will sink back into my well-deserved obscurity as a well-meaning, not to be too kind about it, rube.

What do I say to myself when I find out what a rube I've been, and how I could feel embarrassed when I think about how others might see me?  I say, along with Hyman Roth, when he reflects on how Moe Green was taken out, "This is the life we have chosen."  I have chosen to be a big-mouth and be out there -- or maybe I haven't chosen, maybe that's just the way I am.  There are pluses and there are minuses, and one minus is the constant threat of embarrassment and failure for all to see.  If I'm not going to adjust and be very careful, and look before I leap, I'll just have to learn to live with it.  Which is hard, because I can easily berate myself and find fault with myself and have to talk to myself and say, hey, there are pluses along with the minuses, and "this is the life that I have chosen."  And remember that even if I learn sometimes painfully publicly, at least I do learn, and in the end I hope that I become wiser.

And meanwhile, who knows, maybe they'll publish the letter, and even if I'm not the first to see who is doing what and to call them out, maybe I'll be one of those pounding on the nail into the board until the deed is done, and the feds makes rules that work for people and not large monopolistic institutions who use force, who are bullies, who I have always resented and disliked because of the way I was brought up, to identify with the oppressed, because that's who my ancestors were, the oppressed.

I guess.

Budd Shenkin


Saturday, October 14, 2017

Budd's Encomium

Budd's Encomium

Usually, Budd's Blog is for droll stories illuminative of the human condition, analysis of health care policy, trenchant political insights, and analogies involving sports. And predictions, of course, predicated on establishing the subsequent right to exclaim, “I told you so!”

But today is different. Today, I am posting an encomium I received from the Chairman of the American Academy of Pediatrics Section on Administration and Practice Management (the hallowed SOAPM), along with some other comments from SOAPM members. Paraphrasing Erica Jong, I have to say I have been well and truly honored. As they say, my father would be so proud, and my mother would believe it. And adding to that, my brother Bob said that if the encomium had been declared publicly at the award ceremony rather than posted on the listserve, he would have been compelled to have asked for equal time for a rebuttal. That's what brothers are for, no?

So, here it is:

Hi All
Yesterday, at the NCE here in Chicago, the SOAPM Executive Committee was pleased to recognize Budd N. Shenkin, MD, FAAP with the Charles “Buzzy” Vanchiere award.   The Vanchiere Award, presented annually since 2001, is SOAPM’s highest honor.  It recognizes outstanding contributions in the education of pediatricians in administrative pediatrics, practice management, and payment.    Nominations are submitted annually in the spring by SOAPM members and then selected by the SOAPM executive committee.    
Budd is a native of Philadelphia but has lived and practiced in the San Francisco Bay Area for the past 40 years.  Even in the population of SOAPM overachievers, his credentials and achievements are impressive.  A third-generation physician, he attended Harvard University for undergraduate and medical school.  His postgraduate education includes residencies and certifications in both pediatrics and preventive medicine, a Master of Arts in Public Administration from UC Berkeley, a position as visiting researcher at Sweden’s Stockholm School of Economics, and a Robert Wood Johnson fellowship at UCSF.  In 1979, he founded Bayside Medical Group as a solo practitioner.  Over the next 33 years, he grew his practice to become the largest privately held primary care pediatrics group in the Bay Area, with 10 offices, 35 clinicians, and 150 staff. 
Budd has served the Academy in a variety of roles.  He was on the Committee on Child Health Financing (COCHF) for six years, and recently completed an important role on the Task Force for Pediatric Practice Change, a diverse group of AAP leaders with experience in practice change.
Budd is a deep thinker and an articulate, thoughtful writer and speaker.  He’s authored textbooks and textbook chapters, served on the editorial board of no fewer than five peer-reviewed journals, and gave Congressional testimony to the House Ways and Means Committee in 2009 about health insurance reform.   His style blends medicine, history, management, philosophy, economics, wit, and wisdom, calling on both his impressive academic background as well as his practical life experience in primary care pediatrics.   He is both prophetic and visionary. He advocated for patients taking ownership of their medical records in the New England Journal of Medicine as early as 1973. and wrote an article on the importance of fathers being equal parents in 1992.    He’s sustained that prolific pace of writing. editing, and blogging at <>, more recently as the lead author on the AAP’s policy statement on high deductible health plans. 
Budd completed his six year term on the SOAPM EC last year.  He represented our Section well up to the AAP executive board, inward to SOAPM members, and outward to pediatricians everywhere.  His remarks yesterday at the award presentation reflected his vision for SOAPM taking a deeper and broader role in the AAP.  You can find him this weekend in the SOAPM booth, enthusiastically and energetically encouraging others to join SOAPM, and, of course, every day here on the listserv.
Please join me in congratulating Dr Budd Shenkin, the 2017 recipient of the Vanchiere award!
Christoph Diasio MD FAAP

Suzanne Berman

Hear, hear!

I had forgotten how much stuff Budd has done.

I will add personally that Budd has inspired me in terms of policy writing:

Shortly after I joined COCHF (Committee on Child Health Financing), I offered to write a paper on alternate payment models.  At 5 pages, I thought I had a pretty good summary.  Budd pushed me and stretched me and added little query boxes like "What about this [good idea] or this other [policy consideration]?"

At first I was getting a little irritated with Budd about how much "extra work" he was generating for me.  But at the end of the day, after his last suggestion for clarity or word choice or Daniel Kahnemann reference was satisfied, I had a much better paper.

Thank you, Budd, for kicking my butt towards excellence.


Suzanne Berman, MD, FAAP
Plateau Pediatrics
Crossville, TN 

Brandy McCray

Besides all the fantastic qualities mentioned about Budd above, I would like to mention one of my favorite qualities of Budd - his generosity.

He is generous in his time - offering his thoughts and experiences to anyone that will ask (see Suzanne's example above).

He is generous in spirit - offering his emotional support and examples of his life experiences for those in need.

He is generous in friendship - hosting many for dinner and drinks in his hometown.
And, he is generous as a pediatrician and mentor - sharing many ideas, templates, patient handouts, etc, with anyone that asks.

I am grateful for the opportunity to know him and SOAPM is blessed to have him,
Hear's to Budd!

Brandy McCray, MD
San Antonio, TX

S.F. Khan, MD, FAAP

I have had the most privileged position of being the SOAPMite who lives closest to Budd and have access to tap his wealth of knowledge & expertise amytime, all year round.  And I have exploited that opportunity more than once.

Budd introduced me to a colleague at UCSF with whom I subsequently crafted the series workshop program I am currently teaching there, to an elite (in my opinion) group of residents dedicated to pediatric leadership in underserved services and who could not be more custom designed to eat advocacy for breakfast, lunch & dinner.  That colleague has since become a dear friend.  

Thank you, Budd, for thinking of her and me in the same thought and immediately acting on it.  You are a genuine sage.


Tuesday, October 10, 2017

The Virtues of Professionalism

When you get older you have to be more watchful. You have to think, what could go wrong? Visit the doctor more faithfully, don't drive when you're tired, be more organized so the chance of error is reduced. And, most importantly, beware of falls. Look before you leap. Keep yourself poised carefully on your haunches as you push that trash can down those three steps toward the street on Sunday night for the trash collectors on Monday. Falls are far and away the most looming hazard as you get older.

And I should add that as you get older, you get smaller as your spinal discs shrink as you lose muscle mass and other mass. You lose one inch per decade, we were told at our med school 50th reunion by our classmate Don Smith. I tell people that I myself used to be 6'4” and played shooting guard for the Warriors, although who remembers that now?

But I digress. I was talking about falls, and prevention. Falling is an ever-present danger. My new Blue Hen friend Jim Dean told us that every time he goes to the doctor, the doctor's first question is, “Have you fallen?” It is that present a danger. And we also know that most accidents occur in the home – not surprising, since that's where we are most of the time.

That was when I noticed how dangerous our bathroom is. We have a deep tub, and that is where we shower. Since the tub is deep, we have to perform a balancing act as we get in and out. Stand on left foot, raise right foot high to get over tub wall, stick right foot over tub wall to bathroom surface, place it on floor, shift weight from left to right foot, pick up left foot while balancing on right foot, pull left foot over wall, and place left foot by right foot, at last standing on two feet. Perhaps easier done than said, but still, imagine the hazard.

We were forethoughtful enough to have made the surface of the tub slightly gritty, so that the danger of slipping is minimized. But, and this is a big but, while you are doing all this, there is nothing at all to hold onto. Well, there is the sliding glass partition that keep the shower water from splashing over the bathroom floor, but the frame for those two sliding doors is fragile. If we were to slip and grab the glass doors, they would likely fall down with us and probably shatter. Not much help there.

So I went down to our neighborhood kitchen and bath rehab place, Custom Kitchens, and presented the problem. My idea was that as we climbed in and out, we should have a little grab bar on the counter surface just by the sink, which is very close to where we step in and out. It would be unsightly, it would take space, it would be hard to squeeze the grab bar into that small surface, but it would be safe. The guy at Custom Kitchens thought it could be done, I convinced Ann it was the safe thing to do, and although it took months for the guy at Custom Kitchens to actually get it together, we were ready to go. Safety over style.

Then, and this is the point of this post, there was a switch of personnel assigned to our project. Instead of Eric, Karmela came out to our house and was looking to match colors and surfaces for the grab bar. And then, as she was looking over the project, Karmela said, “You know, there's another option here.”

She looked up from where the grab bar would be and saw that the wall just beyond the end of the tub was just close enough to where we stepped out that she could bolt a retractable grab bar right into it. This retractable bar, or rather a swiveling bar, would be vertically parallel to the wall when in repose, but then when we were ready to use it, we could pull one end of it down so that its length was now perpendicular to the wall – that it, it stuck out from the wall just where we could grab it as we exited. Then it would unobtrusively pivot back up vertical again when we had stepped out, unobtrusively out of the way. Saving the counter surface where the original grab bar would have been, making it look much nicer, preserving precious space in our small bathroom.

Now here's the point. Believe it or not, there is a public policy aspect to this short story. When I exclaimed wonderously how great Karmela was, and she felt proud of herself for coming up with this graceful solution, she told us: when she had gone through her testing to get her license as an interior designer or whatever her qualification is, she had had a task: design a bathroom for a handicapped person. And that is where she had come across a similar solution that she was now applying to us.

A certifying board? Qualification for this rather mundane near-profession? Isn't that just more bureaucracy, designed to keep competitors out, to glorify a job? Isn't this one of those 500 plus boards that have proliferated in the state, that supply sinecures for political supporters to be appointed by the Governor? Isn't that the waste of big government? Haircutters, nail polishers, things you've never heard of, all certified with so-called standards?

You might well say so. I might well have said so. But no more. Sometimes, just sometimes, things work the way they are supposed to. Bless you, Karmela, and bless the board which qualified you. We will now step in and out with both safety and style.

Who says the days of big government are past? Not I.

Budd Shenkin

Wednesday, September 20, 2017

Budd Shenkin's Buzzy Award Remarks

Life is strange, the way things work themselves out. One of my favorite lines comes from Kurt Vonnegut's Sirens of Titan, which I misremember as “I am here because of a series of accidents, as are we all.” It's actually “I am the victim of a series of accidents, as are we all,” but somehow I like my mis-memory better. No life plan, no God's plan, just randomness working its way. As Vonnegut also says in Slaughterhouse 5, “So it goes.”

I got to use that line last Saturday, even though it wasn't in my script but only in the back of my head, and I was so pleased. At last. The way things worked out for me, after I became a pediatrician not knowing if I really wanted to practice medicine, and in fact hadn't envisioned myself being a pediatrician until I found myself (in both senses of the word) on the pediatric wards, and after I found myself running a practice that became a big group, the way things worked out was, after thinking I didn't mesh comfortably with American Academy of Pediatrics, and I didn't mesh comfortably with my home academic university UCSF, the way things worked out was, I found SOAPM, where it turned out I did mesh very well. I found it when a competitive local colleague who was trying to build SOAPM membership and didn't really have my welfare in mind, mentioned to me that SOAPM existed within the AAP and “you should join it.” SOAPM stands for “Section On Administration and Practice Management,” which is what I found the most challenge and pleasure in doing, administering my practice. And so it goes.

So there I was standing before the group of maybe 150 at the convention center in Chicago accepting the annual Buzzy Vanchiere Award, conferred by SOAPM for excellence and service, and I used the line. SOAPM had become my home, where I had served on the Executive Committee for six years, and where I had figuratively sweated and bled for probably 15 years, and where I had found my place. Because of a series of accidents.

As I started my remarks, I noted that the Buzzy Award confers three things. One is what I chose to see as love and respect from my SOAPM colleagues, which I reciprocated enthusiastically – “back atcha!” Seriously, these are wonderful people and some of the best friends of my life. The second Buzzy thing is a $1,000 honorarium, which I am forwarding on to the AAP Building Fund, which I am more than happy to do as a sign of support and respect to the AAP (with more to follow, actually.) And the third thing is: a semi-captive audience. As I noted this, there was a small laugh, perhaps nervous.

An audience. No set subject. What to say? That was the question.

I think a lot about the health care system, and my first impulse was to give a speech about the evolving organizational structure of medicine (see
and the weaponization of EMR's by academic health centers to augment their power and control. But as much fun that would have been for me, not necessarily so much for the audience. So I discarded that idea, other reflections and recollections, and bon mots, and I focused. And what I finally focused on was SOAPM itself. As I thought more and more about it, as I thought about how SOAPM had evolved, and as I thought about the challenges facing the AAP and American medicine, the more I thought that I had something to say about how SOAPM should view itself, and what SOAPM should do, and what the AAP should do. And that became my talk.

So, here it is, my Buzzy talk, edited for readability, and missing some spontaneous emissions when I spoke it, some of which evoked applause and some laughter. But the essence of the message is what we're interested in here.

It got a good reception when I gave it, lots more in the next couple of days, and I hope it leads to action. Now, that would be a real dividend from the Buzzy award.

Budd Shenkin's Buzzy Talk
September 16, 2017
AAP NCE, Chicago, IL

Here in brief, is the message of this address:

SOAPM is a lot more important than we might think it is. It has far exceeded the objectives that the founders of SOAPM hoped for it, and then has gone far beyond them. Given the great changes of organizational structure that the medical world is experiencing, and given the evolving requirements for the AAP to be effective in that medical world, SOAPM is not just another AAP section. It is now more relevant to both the AAP and to the evolving world of health care than anyone could have predicted.

When this happens to an organization, when it becomes very successful and when the world it addresses changes, one has to reassess the organization’s structure and the resources devoted to it. Just so with SOAPM. I believe that SOAPM needs to be reevaluated, to be strengthened, and that our basic organization probably needs to be updated.

Because I think it's possible that, great as SOAPM is, you ain't seen nothing yet.

To make that case, briefly, I intend to look at the past, the present, and the future.

What we have done so far

SOAPM has been a roaring success.

  • We have increased our membership to over 1,200, and we are arguably the most dynamic section or committee within the AAP.
  • I don't know if the founders would be surprised or not, but I'm certain they would be gratified.

The Original Agenda

I think the SOAPM founders hoped that the section would:

  • concentrate on helping each other run practices.
  • educate the rest of the Academy on how to do it.
  • and show the Academy how important administration and management is.

This is still mostly what we do.

  • We help with coding.
  • We trade tips about how to organize our offices.
  • We coach on how to deal with insurance companies
  • We give lots of educational sessions on management topics – Herschel himself has become a virtual education industry.
  • We have constructed a huge storehouse of documents on how-to.
  • Not to mention that we are the world's leading repository for vaccine-refrigeration and disaster preparedness information at our subsidiary office in North Carolina.

I think this was the original agenda. No doubt we have exceeded hopes and expectations.

Possibly part of the original agenda

It's hard to know if the founders envisioned this, but SOAPM has been successful in helping Academy statements and projects to be practical and relevant. There are innumerable instances where this has happened, but just to name two:

  • No unfunded mandates – want us to do some things for Bright Futures? OK, we have to be paid to do it.
  • Practice responsibilities for vaccine refusing families – we now have freedom to refuse them as patients, and as a result we think many more families will be vaccinated.

Probably not part of the original agenda

Amazingly, SOAPM has been able to help the Academy recognize a new facet of its mission. Traditionally and appropriately, the Academy has stood fast in its determination to improve the health of children. Now, even though we recognize that the Academy is not a trade association, it is now considered legitimate that the Academy consider protecting and improving the health of our practices as part of its mission. The health of pediatrician practices, whether independent or within networks and groups, is now recognized to be strongly connected to the health of children. That is thanks to SOAPM. We have exceeded the original vision here.

Also probably not part of the original agenda

SOAPM has also exceeded its original charter by reaching out to try to affect the actions of organizations external to the Academy.

  • Trying to influence NCQA and make their measures palatable to pediatricians seeking to qualify as Patient Centered Medical Homes.
  • Trying to help CDC improve flu shot distribution.
  • Trying to rationalize the VFC program.
  • Trying to help Feds get coding straight.
  • Trying to get the American Board of Pediatrics to straighten out its act.
Truthfully, we have been only partially successful in these efforts, and SOAPM and the Academy are still not sure how assertive to be. But we seem to be on the road to becoming more successful.

Certainly not part of the original agenda

There's one thing they couldn't have envisioned in founding SOAPM – the listserve, because the technology wasn't there yet. The listserve has proved to be the X-factor that has multiplied the impact and importance of SOAPM immeasurably.

We use it:

  • To fulfill our main mission, to trade knowledge and views on practice administration, on interventions with insurance companies, on coding, etc.
  • To trade clinical information, which is so enlightening and so much fun.
  • To trade information on outrages by everyone, from government to patients and not excluding the Academy.
  • To trade opinions.
  • To keep up with and deepen our knowledge of policy
  • Etc.

And then there's something much deeper that the listserve has gifted us with, besides making sure that we “get mail.”

The listserve is what has led us to become a great virtual community. We are a community. We care for each other, we reach out to each other, we have come to know each other and help each other, and to forge bonds of affection born of discovery. We feel about each other: where were you all this time I've been looking for you?

And, the listserve has uncovered great intelligence and talents. Aren’t you just blown away by some of the things we hear that people are thinking? We have so many smart people here. And idealists. Yes, make sure we are paid for what we do – but the true idealism of people, the embodiment of the true mission of medicine, of pediatrics, shines through. You are some of the finest people I have ever known. SOAPM is a testament to the power of a listserve!

So, this is only a partial list of activities and accomplishments. SOAPM has been, and continues to be, a roaring success. We have punched far above our weight. We are all so blessed to be part of it.

The Future Agenda, and Our Organization – Aspirational Goals

KEY POINT: Even as successful as we have been, SOAPM could actually be even more than what we have become. Our task at this point, I think, is to envision our future.

First Point

Health care’s organizational structure is changing very profoundly and quickly. Everything is getting much more agglomerated and corporatized. This presents us with a very potent challenge. New entities are arising, such as RBC’s and UC’s for after-hours care, networks, other agglomerative bodies. And in fact, we need to recognize that over half of us are now employed physicians! Not that there's anything wrong with that. Employed pediatricians aren't that different from those of use who are independent. The majority of pediatricians are eager to serve patients well, and to improve the systems that they are part of, and to make sure that they themselves thrive in the process.

But while increasing size can be good, it is also a threat.

  • It's a threat to patients – bureaucratic medicine can be harmful to your health.
  • It's a threat to us – some of us would rather quit than become a cog in a corporate wheel.
  • And to those of us who are working in larger systems, we need a lot of help in coping with the bureaucracy that we are part of, to survive happily, and to improve the systems of care that we are part of.

With all this change, where is the voice of primary care pediatrics? Where is the voice of primary care that knows organization, administration, and business? Nowhere else but SOAPM. We are much more important than we realize, and more important than others realize.

Recall the Indian parable of the blind men trying to describe the elephant. One of them says, “An elephant is a round, very heavy immobile post.” Another feeling the ear says, “No, it is thin and long and floppy.” A third says, “No, it is long and round, flexible and strong, with a hole in the middle.” To understand what an elephant is like, they have to communicate and to accept what the other is saying, without the arrogance of thinking that they are the only one who is right.

What is the point of view that SOAPM has to contribute to the ongoing puzzle of reforming the health care system?

We have a point of view that is invaluable. We are where the rubber hits the road, since we actually see patients day after day, not two half days a week; we are the ones who devise the processes and implement in real time what others only imagine; we see what is actually happening as a result of policies. We know how to design systems that work.

Yet we struggle to get our voices heard, within the AAP, and in the larger medical world. Other forces are very powerful – from insurance companies, from PhD's and MBA's, from hospital administrators, from the large academic centers, from the procedural specialists. They have the arrogance of power and money. They really don't want to hear us. So we have to insist.

We need to be at the table and not on the menu! We are important and we shouldn't have to fight our way into every discussion, into every policy argument. We shouldn't be treated like step-children. The AAP should be bringing us in on just about everything, not just having things handled by a few Board members and some top staff. On SOAPM'S behalf, I want in, and I don't want to have to fight for it.

A case in point is policy on after-hours care units, RBC's and UC's. Jim Perrin tried to bring order out of chaos by developing a policy centered on the Task Force on Pediatric Practice Change, and did a good job, but then the TFOPPC's sun set. Currently, this policy just goes floating around – this policy needs a home, and it should be with us. That's just an example. More generally, the Academy needs a center to consider issues that arise on the organizational structure of health care, and I nominate SOAPM to fill that vacuum.

In sum, in these new times, SOAPM is more important than ever.

Second Point

If we are going to meet this challenge, we need to consider our own internal organization. While the world and our functions have changed dramatically since SOAPM was founded, we are still organized exactly the way we were twenty years ago, and we still have the same resources.

For one thing, we need to run SOAPM like a business! This point has been made most cogently by Jeanne Marconi and Sue Kressly on the EC. We don't need to reorganize to make money – that's not the point. (Although business is our business. We wish the Acadmy would turn to us for some business advice instead of hiring consultants – that's another function we could serve.) But we need to have agendas, a list of things we want to accomplish and means to accomplish them with timelines, on objectives that are widely accepted within SOAPM. We all in SOAPM should be aware of our agenda and have a chance to help shape it. And it should be visible to and approved by the higher administration.

We also need to make better use of our member resources. Jon Caine and Glenn Schlundt, Peter Pogacar, members of the EC, so many others, so smart! Yet, the discussions and analyses just vanish into the electronic ether of the listserve. They shouldn't! We have huge intellectual resources that are being suffocated here within SOAPM. (At the very least, by the way, our journal Pediatrics should modernize itself and have a section devoted to policy and management articles.)

The mark of an excellent organization is one that identifies, nurtures, and makes use of the excellence in its workforce. We need to organize ourselves so that we do that effectively.

Maybe it is no longer appropriate that SOAPM should be a section. I'm not sure what other form we should take, but we should be immediately accessible to the Board and the CEO, and we should be able to be the repository for policies concerning organization of care and be able to produce policy papers.

More generally, the policy world is crying for primary care leadership, and we should press the AAP to use us to supply that leadership.

We will need more resources for this – we actually need more resources just to continue what we are already doing.

For us to achieve a new organizational form and placement, we need a first action step. I propose that we establish a task force of 10-15 people, from SOAPM, from the Board, and including a representative of the CEO, to reexamine the structure and function of SOAPM and come up with alternatives for the future.

We have grown; now we need to differentiate. An organization that is not going forward is going backward. Let's not be like Kodak - they owned the world of imaging for a hundred years.  But they took their eye off the future of their industry and quickly became irrelevant.


So, my message is simple. We have been a great success. We have given to ourselves, we have given to the Academy, we have given to our patients. But it's time for us to think bigger. What more can we do with more staff, more involvement from our membership, a more prominent place in the AAP, a more businesslike organization?

I say, let's give it a try.

Budd Shenkin

Sunday, August 20, 2017

Do The Democrats Belong In The Major Leagues?

I believe there is very little in life that cannot be illuminated by a reference to baseball, and if not baseball, then basketball.

Take our political situation. Our team is the Democrats. We can love them, we can hate them, we can hold grudges – my grudge against Hillary and the other Clintons hasn't shown signs of weakening, and I voted for them but I think no matter the opposition I would vote against $50 millionairess Chelsea, since even home team allegiance has limits – we can deplore their ineptitude, but they are our team. We can admire players on the other team, from time to time, but the admiration always has to be somewhat grudging, because they are the opposition. Mantle was great, but not ours. Ted Williams – well, there's the exception, especially because he was always so beleaguered, he was called back to service for the Korean War for God's sake, and he never won it all.

But anyway, when you are losing badly, the dreaded word “rebuilding” comes up from the depths. Can anyone be more in the depths than the Dems? Statehouses, state legislatures, House, Senate, Presidency, and the stolen Supreme Court? All gone, ladies and gentlemen, all gone. How can you not think, “rebuilding time!”

How did we get here? I indict Hillary and the Clintons, of course, that's an easy call. Ineptitude, here is your avatar, losing an unlosable election by playing – OK, switching sports – a prevent defense, for God's sake. We all know by now that a prevent defense prevents winning. I'm still getting posts on Facebook of Hillary warning against Trump. Yes, she was right, of course she was right. But it was still a stupid thing to do. Your mean teacher warning you – that's sure a winner. Just as it was stupid for Hillary and Bill, with their famous long memories and penchants for revenge, to squash any young pretenders of any possible support, so the only challenge came from Bernie. Yes, he did a great job, but come on, can you think that one-track Bernie, right as he may be on that single track, is the future of the franchise? A great free agent from the land of the Independent, admirable, an amazing season, it would be great to see him do something again, but the future? Maybe a guide, but not the strong shoulders to lift everyone up, not a Mike Trout to build around. But he was all that was left.

Strong leaders build strong teams. They go out and recruit the Kevin Durant and pledge to play together and love one another. They don't protect themselves by bringing on dwarfs like Debbie Wasserman-Schultz. Yes, Hillary looked like the charming one in comparison to ol' Debbie, but come on, man.

And much as we love and admire BHO – I don't think that set of initials is going to stick as well as, say, KD (love KD!) – he didn't build a strong legacy. He didn't educate the country, he didn't as they say “change the conversation,” he didn't find the great leaders and promote them. He stuck us with Hillary, sorry to say. He doesn't seem to be gregarious, he hung out with young staff guys and his golf crowd, so how could he find out who was a hot comer? He couldn't even remember Pete Buttigieg's name when asked for the possible rising stars, calling him “the Mayor of South Bend, that guy” – Bill Clinton would know his name and his boyfriend's name, how to seduce him politically, what his weakness was, and would have found him a role and made sure he wasn't threatening – but that was his weakness, not strengthening people.

Obama left us with very little. Maybe it's not his fault, but I think it really is. Great guy with many weaknesses, and one of them was not making use of his great strength of expression. Where were the great speeches building a program legacy? Where were his close allies ready to take charge? Maybe he'll come through now, maybe. He's so smart and he can really learn.

OK, so we're rebuilding. When teams rebuild, they look to their farm system, and they trade for the future. Well, trading's not something to rely on in politics, but the farm system, that's where you have to look, and you have to recognize when the old team is lagging. Nancy and Steny might still have knowledge and strength, but they're losing, so time to pack up. Sorry. Nice job.

To find the new stars, there's no way to tell who can do it without putting them in the batter's box. This is the time, just like when the current season is gone, put the young guys in and see who can throw strikes for outs and who can hit major league pitching. With the midterms lurking, it's time not only to see what candidates can run well in the districts, but higher up in the order, who can go around to the districts and give speeches for those guys and gals, who can make the good connections on a personal level, who can strike the right notes, hit the singles and doubles all across the country and head for the middle of next year's lineup. It's tryout time.

Trump is throwing a fastball right across the middle, and his team can't get rid of him with his unbreakable contract. Now, who on our Dem team can hit those pitches out of the park? Somebody should be able. We're looking around for them. We see them coming through MSNBC, and then we'll see who can go around to the various ballparks and prove they belong in the show.

The message? They'll have to form the message. We know the outline; the stars will have to fill in the blanks and express it their way. The ownership can't do it – “A Better Deal” proves that point. We'll see how the show gets formed on the road, to mix show biz into the analogy. You find the stars, and then you field the team around them. Politics should be a team sport.

There is no guarantee that the team will assemble itself into a winner, of course. There is an opposing team, and they have journeymen masquerading as stars, I'd say – but they are familiar by now and well on their way to winnowing down to their strongest. And the old line Dems could still hold sway. I'm from Philadelphia, and any fan from Philly knows how to suffer. I remember Connie Mack. In those pre-free agency days Mack not only managed the A's, he was the owner, so he couldn't be fired. Decades of frustration were the product of stagnation. What did he care? The A's were “his team.”

Ownership is key to winning; look how the derelict Warriors transformed themselves when the Milwaukee group bought them and hired Don Nelson in the 80's, and how the story repeated itself in spades these last five years to produce one of the finest teams ever. Not only ownership willing to spend, but ownership willing to bring in Jerry West and to listen to him, to bring in Bob Myers and let him operate, ownership willing to play the true ownership role.

Ownership in politics has changed from the years of Bob Strauss and the backroom boys. I'm not sure how it works now. But in the end, either the old Dems will keep holding sway, or a new group of owners will emerge to identify the stars and produce an organization that actually functions, unlike the DNC who couldn't even respond when they found they were being hacked. Seriously, they couldn't. And they couldn't bring out the voters who would make a difference in Milwaukee, in Philly, in Michigan. What a horrible organization. (I wish they would stop calling our home for donations, Jesus, enough already! We're not giving you a cent! Or at least I'm not; I can't speak for Ann. She's probably more level-headed than I am.) But maybe Bernie and Obama can make peace and with a few others – please keep Hillary out! – see which of the youngsters is hitting and give them the support they need.

So, that's the deal now. Who can find the right balance of decrying the Republicans and offering a vision of hope and progress that makes sense, who can go to the ballparks across the country and keep getting hits? And when the stars emerge, as they will, can there be an ownership to guide them into a team that brings all the strengths together?

Remember, Cornelius McGillicuddy's A's eventually moved to Oakland with a different owner and produced some of the finest teams in history. They actually rebuilt under new ownership, and the result was, as they say, history. I can't say that I still don't hold a grudge against Connie Mack, and against Hillary, but there's nothing like winning to take the edge off.

I'm ready for the new season. More than ready. But if they mess it up again, then you finally have to say, we need a new team to be able to compete in the Majors. I'm hopeful it doesn't come to that.

Budd Shenkin

Monday, August 7, 2017

The Weight of Ink, by Rachel Kadish

Sometimes, you just don't where it will come from. My favorite book for this summer is The Weight of Ink by Rachel Kadish. The name “Kadish” is probably not familiar to you, but it's the name of one of my best friends in medical school, Larry Kadish. We were guards together on many a basketball team. We worked well together, mutual respect and affection. He told me, one of the great compliments of my life, that I could be hung over, exhausted, or sick, no matter, I would always get my points. How can I not love Larry?

Then, halfway through med school he married one of our classmates, Anna Stein, from New York, but before that from Holocaust Poland to the US through the Eastern route. At our reunion in June, I told Anna that I played cards with a fellow Jewish pediatrician who was from Shanghai originally, and I had told him that my classmate Anna had escaped through China. “Japan,” she said, “but close enough.”

I still feel a little guilty that when Anna went into labor and I had volunteered to stay with Larry while she was in labor – in those days I had the idea that men stayed outside the delivery room and smoked, although neither of us did, but maybe we would – but when she went into labor I was at home in Philadelphia and missed my support role, which was big in my eyes. I called Larry a few years ago to apologize, get it off my chest. “That's OK,” said Larry, “I really don't remember anything about it (about my promise to be there, not the birth).” Maybe I wasn't as central to that story as I thought I was.

So, Larry and Anna have a daughter, Rachel. I don't even know which child she is, 1, 2, 3, or 4, but she's in there somewhere. And it turns out she is a writer of novels. They have admirable restraint and didn't go all around the reunion saying that their daughter's book was coming out, after 12 years of working on it, at least not to me, but Ann finally couldn't help it, she posted the link to a New York radio interview of Rachel on our class listserve, not saying anything, just posting it. (

Out of loyalty to them I felt I had to listen, and the book sounded interesting and she sounded charming and intelligent and winning, although if she weren't their kid I wouldn't have voluntarily picked up a book about a blind Jewish rabbi and his female scribe in 17th century London. But I then ordered it on Amazon and put it ahead of finishing my current book, the newest Hitler biography (it's very good – hadn't really understood at all about the Beer Hall Putsch and Weimar Germany).

But then as I read, I found that I couldn't put it down. It's just one of those books you hope to find, a book that you hurry through to the end because you can't put it down but that you don't want to really end. A book that you want to keep with you if you can, maybe just to be able to look at its cover. Twelve years, and it reads not at all like the ponderous title of weighty ink, but flowing sentences, good sentences, and an intricate plot that connects all the way through – at least I think it does, I'm not real good on plot lines.

It's one of those books that alternates chapters of two different stories that are connected. One is the accidental discovery in 2001, in a house dating from the 17th century, as it is being redone and updated to greet the public as a museum, of a set of manuscripts from that period. The owner calls his old medieval history professor, Helen Watt, a seemingly severe English woman about to retire, who we find has a history of being a gentile in the new Jewish land of Israel where she fell in love with an Israeli and loves him still, although in absentia, since it didn't work out. She recruits an American Jewish doctoral candidate, Aaron Levy, to help her. Both are fluent in English, Hebrew, Portuguese, and Latin, I think, and they piece together the meaning of the documents and the history of the people, as they battle in the competitive academic bureaucracy. It is the find of a lifetime, this set of manuscripts of the letters of the rabbi and household accounts. Gradually they piece together the story.

We, however, know much more than they do, because every other chapter traces the life of the rabbi and, more centrally, the scribe, Ester Velasquez, both of whom were exiled from Portugal, the rabbi blinded by the Inquisition, then to Amsterdam, and thence to London in the continuing diaspora. London accepted Jews under Cromwell, perhaps for the business, perhaps because the Bible foretold that the Messiah will appear only when Jews are everywhere. A great picture of what life must have been like for these Jews, the women working hard in the houses and aspiring to little but husbands, the wealthy and the poor living very different lives, the continuing value of learning, life as it must have been lived in the Interregnum and the Restoration. But the excitement of the 17th century story is not only the personal stories – which are good – but the intellectual progress of Ester, and through her, letting us see what the Jews were thinking about, and contending about. Letters go out to many of the well known intellectuals with Ester's razor-sharp questions and logic, to be answered by some, including Spinoza. She resists marriage as it would be a cage, at least until the great plague, and then the fire. It's a compelling, compelling story.

Helen and Aaron, meanwhile, have their own trials to endure, they own paths to follow, their own dilemmas to be faced, their own characters to be probed. The introverted English and the extroverted American, familiar territory, but wonderfully evolved. And in both parallel stories, there is so much of the lives of women, and men, and the process of choosing a mate for feeling and the risks of doing so, and chance, and the continuing story of the Jews, of whom I am one but of which I know so little. I knew in theory what a feat it has been to keep a people alive as a people for eons without a homeland to live in, but this book lets me see that a lot more clearly. It's a serious book, but an intimate one, with continuously touching stories, the kind where you want to break the fourth wall and talk to them. This daughter of Larry and Anna can write.

And then I finished and I reread the comments on the book cover. The front cover has from Toni Morrison: “A gifted writer, astonishingly adept at nuance, narration, and the politics of passion.” I hadn't thought about passion having politics, but now that she points it out, I guess that's right. The back cover has compliments from five authors, and it was only at that point that I realized they were all women. What I had read and loved was a feminist book! Yes, I realized all the way through that she did women better than men, but I hadn't realized that so much of what she was writing about was the plight of women, and the over-weaning nature of so many of the men, although there were good ones, to be sure. But we don't see them as intimately as the women. How come I didn't notice?

Well, I don't notice a lot of things, and when it comes to fiction, I'm no expert, I'm more of an “I like it” kind of guy. Although when pressed, I guess I can hold my own. And I do hope I get pressed on this one, because I think it's a deep, rich book, one that can stand a lot of examination and discussion, and a lot of love.

I wish I could say that is the child whose birth I missed, but probably not, probably a later one. But whatever, even though I don't see them much, these are my dear friends, my classmates, and they have birthed and nurtured someone who has worked so very hard at her craft to be able to produce such a book, and worked very hard to learn enough to produce this very one. As I wrote to Larry and Anna when I was on about page 75, I think this should be a National Book Award contender. I'll stick with that.

Larry, it might be true that I will always get my points, but Rachel has just racked up a lot more than I ever could.

Budd Shenkin