Monday, January 22, 2018

The Candidate's Creed: Decency, Humaneness, and Fairness


Why can't we have a government that is decent, humane, and fair? There are other things the government needs to be – strong, intelligent, protective, to name just three – but if you and your government are not decent, humane, and fair, all the rest will not matter.

What is it to be decent? Decent people and decent governments are respectful of others. They do not bully, they do not belittle, they respect truth, they respect the beliefs of others, they seek goodwill in themselves and in others. They are not perfect, but they try to be better, and they seek the better angels in themselves and in others. They do not put themselves first in line, they sacrifice for the good of others. They contribute their fair share, and more when they can. They seek to do what's right because it is right, not because of what they hope to gain from it. They understand their limitations. They applaud the strengths of others.

What is it to be humane? We are all on this earth together at the same time; others have come before us and given us much; others will succeed us as we pass on our land and air and water and civilization to them, along with the knowledge and beliefs that we think worthy of being passed on. While we are here, living together, some will be happy while others grieve; later on, the grieving will recover and the happy will be afflicted. It is never equal, and happiness and grief come from different sources – health, wealth, the joys of living the good life. Helping others to succeed, helping others to find meaning in their work, helping others to be happy and healthy and productive, not holding others to standards that are unreasonable and that we ourselves would not want to be held to, understanding the different circumstances and capacities of others and allowing for both weaknesses and strengths – these are the standards of being humane that both governments and people need to aspire to.

What is it to be fair? The Golden Rule is not the property of any one religion, the Golden Rule is the property of all of mankind. Indeed, it is the property of more than mankind. Chimpanzees understand unfairness when they see it; they spit at the handlers who favor one chimp over another; and the favored chimp seeks to redress the balance in favor of the chimp afflicted with unfairness. Can people and their governments do any less than chimpanzees, or must the extra capacities of our brains be used to accentuate and perpetuate unfairness? Unfairness is heaping more privilege on the privileged, erecting rules that perpetuate advantage, rather than redressing it. Unfairness is also not allowing those who have worked hard and produced excellence to benefit from the fruits of their efforts and abilities, whether they are at the bottom or the top of the ladder. Unfairness is denying the basic democratic rights, the basic human rights of participating and voting in an equal manner. Fairness is inclusiveness; unfairness is divisiveness.

So I stand before you today to say that, although we are all beset by human frailties, of inabilities to distinguish the good and the true, of cloudiness of vision, nonetheless, despite these frailties, I declare that as your representative, I will be just that – your representative. And as such, I will seek to represent the best that is in you and in us. I will seek to improve our government's actions to be be more decent, more humane, and more fair than it has ever been. That will be my goal.

Now, on each issue honest people will differ on what is decent, humane, and fair. That is normal. But what is not normal is for Americans to declare that decency is passé, that humaneness can be abandoned, and that fairness means acceding to the power of bullies with money. Today's politics are not normal and are indeed dangerous, because we see all around us those who would deny those basic virtues. It is sad to think, but instead of assuming that these virtues are respected – virtues we sometimes call “norms” – today it is necessary to stand up, to state those virtues distinctly, and to insist that they be observed and respected. It is sad to think that this is necessary, but it is, it just is.

So I stand before you as the candidate that will state and restate the necessity of being decent, humane, and fair, and who will try my hardest to identify in each issue what is the more decent, most humane, and fairest solution, and who will fight my hardest to make the government take that course. Others will differ in their solutions; that's politics, that's being human. And if they can make the case that their solution is decent, humane, and fair, then we will listen to them and strive to reach an understanding.

But, if they say that decency is unnecessary, that humaneness is profligate softness, that fairness means prostrating ourselves before the rich and the powerful, then I say we will not listen to them. Those are the voices of perdition, the voices of destruction of the individual and the spirit, as well as the state. We will not listen and compromise with the voices of destruction. Instead, we will fight to the end to uphold our belief in what is well known (if now a cliché) as our “core values.”

We will not allow ourselves to be debased below even the level of primates with smaller brains. Instead, we will use our brains and our hearts and our spirits to support the vision of good men and women from the generations who came before us, and to add our modest contribution to those who will come after, and we will reaffirm with vigor and strength that decency, humaneness, and fairness shall not be diminished, but instead will be reinvigorated, that we shall withstand this test and emerge even stronger than before, proving that our vision of the good life for all of us will remain intact.

I thank you for your attention, and I ask for your support.

Budd Shenkin

Saturday, January 6, 2018

The Fairness Gene and Political Strategy


“Not fair!” rings the cry of the sibling assigned to wash the dishes that day. In a family of legal disputants, claims and evidence are mounted. In a liberal and controversy-avoiding household, tasks can then be rearranged. “Not fair!” is a ringing call to arms that everyone can understand, at least in a liberal household. They say that in conservative households “respect and obey” rings louder. Maybe. I never lived in that kind of household, and we never voted Republican. Although my father said he voted for Eisenhower the second time around. Maybe he was making good money by then.

Anyway, it turns out that you don't have to have words to believe in the cogency of “not fair!” Primates do it, wolves do it, even fish do it. http://science.sciencemag.org/content/346/6207/1251776. If you are a social and cooperative animal, you evolve to have a sense of fairness.


What kind of country is Iran? It is a kleptocracy, he says. Sounds right to me. How to approach it, how to help the oppressed people? Give them the facts on the kleptocracy, who is taking what. I read elsewhere that what set off the demonstrations was Rohani's publishing the budget, so that it became clear who was getting what. Nothing like the facts of a kleptocracy to kindle “not fair!” at least in a society that has not bred out the fairness gene. Seems to me that in some societies “respect and obey” might take precedence in a significant sector – see, Russia. But what Stephens says makes sense to me – just the facts, ma'am. Let the fairness gene take over.

Which is pretty much my advice for Democratic candidates, too. You can make fun of Trump, that's always a kick, and the Trump Crime Family, where competition for dullest of the dull is fierce. Snark. Can't resist. But I should, and so should the Dems. Mocking can come back to bite you. Better to use the fairness gene.

The Republicans are not being fair. They are taking all the money for themselves. Just prove it, and let the voters make their decisions. Pictures – posters – over and over again of the fat cats and what they are taking away by virtue of the Tax Kleptocracy Bill.

Follow the theme with a little variety. They are taking the environment away from the people and using it for themselves, to make money. Poster child, Ryan Zinke. Really, let's have posters. His slogan, “It's (a) mine!” Picture of shrunken national monument and superimposed mining equipment, Zinke in private jet buzzing the monument.

Picture of elfin Jeff Sessions pulling a reefer out of someone's mouth, “I'll take that!” Yes, he will, he certainly will.

Picture of ICE throwing a mother out of the country with caption, “This land is my land!” with crying Woody Guthrie on the side. “Mine!” The cry of two year olds!

So, that's my election strategy advice. Attribute to Republicans the slogan: “THIS LAND IS MY LAND AND YOU CAN SHUT THE FUCK UP!”

Works for me.

Budd Shenkin

Monday, December 25, 2017

Merry Christmas


I had an aberrant reaction the other day.

Friday night at about 10 PM I got a text from our neighbor, Paula. She said to call her if I was up, which I was, and which I did. Paula had found the remnants of two packages, one a Honey Baked Ham that Ann had ordered for the holidays, and one an Amazon package. The contents of each were long gone. Then in the morning I found on our doorstep the remnants of another Amazon package addressed to our son Peter, placed there by our neighbor Cinda, who had found it up the street while walking her dog. The doorway package thieves had hit our neighborhood, or at least our house.

Everyone feels violated by thievery, and so did I. What didn't happen to me, interestingly, was that I didn't feel angry, at least not much. Sad, yes. But then, I thought, it wasn't much. I talked to Ann, who was in the city overnight with daughter Sara and granddaughter Lola at their annual Girls Night Out, celebrated by Lola annually by telling me, “You can't come, Baba, because you're a boy!” Ann was upset because part of her plan for the holiday was having ham available, which signifies something about Christmas to her. I told her I could drive down to Costco and get a spiral sliced ham that we had ogled last week. She told me that she would hate for me to have to do that, but I told her I'd be happy to do it, because who would be at Costco three days before Christmas, anyway?

So off I went to Costco. There was very little traffic but of course that changed as I drew closer. Luckily, I was able to be in the faster left lane up the off ramp which others apparently didn't know was a “right turn OK” lane, and then was able to stay in the left lane until the very end in the approach to the entrance and move to the right at the end with huge holes in traffic in the right lane– amateurs driving! – and then had to find a parking space in front of the convenience store by the Shell station, but there was an open space right there. Located spiral sliced ham – they had moved it from last time, which is what Costco does – and grabbed some baguettes, some sandwich meats and sandwich rolls and pumpkin pie and bottle of wine and shrimp and wrap sandwiches God forbid we should go hungry – and approached to check out counters with six people deep until the attendant waived us over to the lesser used lanes where I was second in line to someone with really minimal goods to check and VOILÁ – out the door! God was smiling, fast trip to Costco three days out? Come on!

Back to the car, saw other carts abandoned here and there but I was a good boy and took mine back to a station. Pulled out of my space and saw the exit lane jammed with little movement. And then I saw myself doing something Christmasy – coming down the opposite lane and contending with me for the next spot in line was a white SUV with a family, two adults and two children – and instead of taking the space, I waved them in in front of me. Here I was, recently aggrieved by theft, but blessed by express lanes one after the other, finding lots of food to offer family, and I was responding by passing on the beneficence.

And I noted what I was thinking. I was thinking how lucky we are that the theft of food and presents really doesn't mean anything to us. I remembered the stories of people who remembered that when they were kids their mother took them downtown to look at the store windows but who didn't get presents because they couldn't afford them. I remembered that there is a big difference between those who have enough and those who don't, but a small difference between those who have enough and those who have more than enough. Am I going to get upset because some blighted souls afflicted us? If I did, I should feel ashamed of myself.

But no need to feel ashamed. Instead of being aggrieved, I was feeling lucky and fortunate. That's strange, but welcome. Me, a sunny guy? Me? Mature? Wow.

It must be sneaking up on me.

Merry Christmas!

Budd Shenkin

Saturday, December 16, 2017

On Conveying Our Truths


When most of your tomorrows are behind you, making sense of your life becomes more desperate. How to convey what you don't quite understand? Not in reduction, not in deduction, certainly not in subduction, but in their opposites: compilation and induction and unearthing, as conveyed by suggestion, implication, and innuendo; as observed by glimpses askance and the elevation of partial truths that may imply other partial truths, all we can catch with our wavering eyes.

What evanescent specks we are, we know; how much we have simply borrowed from others, we suspect. But even if we have rediscovered truths and simply applied them to new circumstances, they are ours, and we can convey them truthfully and righteously and with the conviction of having lived it, and we can only hope that others will make them theirs as well.

Budd Shenkin

Tuesday, December 12, 2017

CVS-Aetna Merger and Retail Based Clinics


CVS-Aetna merger, will it happen? Probably, because the FTC and Justice Department no longer worry much about size, although it's possible that their rejection of the Time-Warner/ATT merger might portend a changed view, or it might be only an evanescent political transaction. Whatever.

If it does happen, one of the effects could well be further expansion of Retail Based Clinics. I have an economist friend who thinks this could be good: more competition favoring increased access and efficiency. I take a different view. I think RBC's decrease quality inexorably. I wish I could move the American Academy of Pediatrics to take a robust view here and protect America's children from bad medical care, but no can do, have tried. Can't move that bureaucracy.

See my prior post on RBC's, and why they are a very poor idea –

So I'm reduced to posting, here on my blog, and on the Section on Administration and Practice Management listserve, albeit this comes with the feeling of pissing into the ocean. Ahh, well, life in the big city.

But I have to say, posting on the listserve has its rewards, not only in the relief of getting something off my chest, but then provoking learned and amusing rejoinders. For the edification of my readers, here are three trenchant comments that boldly foresee the potential results of this merger and RBC expansion.

1. All Aetna patients will have lower drug co-pays...but only if the prescriptions are filled at CVS.
2. Aetna patients will have $0.00 co-pays for all Minute Clinic visits, plus they receive a $10.00 coupon to use at CVS...but only that same day.
3. Aetna patients are welcome to the Minute Clinic for all their Immunizations without those annoying annual well exams. 
4. No appointment? No problem! No wait Sports Clearance exams. In and out in 10 minutes guaranteed or we give you a $10.00 same day credit to use at CVS. 
5. Are you tired of those long waits at your Pediatrician's office for those annual well exams? Tired of answering those same stupid questions about how your kids are developing? Tired of your Pediatrician asking those personal questions about your Family History? Tired of your Pediatrician waiting until you leave the room until they ask your children questions about sex, drugs, sexual orientation and God knows what else? Well come to see us at CVS. We do none of that. Try our 10 by 10 physicals. $10.00 and 10 minutes to get that priceless piece of paper so your child can play football, or soccer, or field hockey. And don't worry. If by some small chance we actually pick up any abnormalities in your child we will try our best to mail a copy of our note from our central office in East Ekvelt, RI to a pediatrician of your choosing within 10 business days. 

What's wrong with that??

Jon Caine, MD

6. And should your child have an adverse reaction to the Z-pack that everyone with a cough is given ($10 CVS coupon if we fail to prescribe the antibiotic of your choice at the time of your visit), never fear. Your child’s pediatrician is under contract to Aetna to provide coverage 24/7/365, and respond to your call within 30 minutes. 
7. In our quest to provide quality healthcare at a reasonable cost, your child’s pediatrician will see a reduction in payment if an antibiotic is prescribed within three days of your child being diagnosed with a cold. Here at CVS/Aetna, we win both ways when that happens: More business for the pharmacy AND a lower medical cost ratio! Our stockholders are thrilled!

Jesse Hackell MD


And…once they are the only health plan in a region, they will rejuvenate shopping centers which have turned to Dave and Busters as their anchor.  There is no room in a CVS for 100 visits/hr, so they will lease all of those struggling store fronts and open up The Thoracic Outlet Mall with stores becoming physician, I mean NP specialty centers like the Hair Transplantary, Bananas Republic Urology, Gourdstoms Neurology, Victoria’s Secret gynecology, and, of course back from the gas chamber, Farts Authority GI group.

Russell Libby, MD


Thanks, guys – you outdid yourselves again!

Budd Shenkin

Sunday, December 10, 2017

Goddamn Surgeons


When I was in practice, we sometimes ran into this situation: our patient needed to be seen by an orthopedic surgeon, and the team at Children's Hospital in Oakland was in great demand. So here was how they triaged who they would see. They assayed the chances that the patient would need surgery – the remunerative part of their practice (although truth to tell, they make so much from their office visits – a couple hundred bucks for five minutes is not unusual – that one wonders.) Anyway, we could always beg as a tactic and sometimes that worked. But then UCSF provided some some competition with a nice female peds orthopod who would see everyone and who tried to err on the side of not operating, we started referring more to her, and magically the Children's Hospital orthopods were more willing to see all of our patients.

Last night I saw my friend Jeff, from our book club, at our friend Norm's birthday party. Jeff had been suffering from a foot condition and had put off surgery for fear that it wouldn't be successful. His pain became unbearable so he had the operation, and happily, it was successful. He even danced at the party, or at least that was what he claimed he was doing; objective observers were split on their interpretations. But the foot looked fine, and he said he is now pain free. It is so great that modern medicine can successfully treat conditions big and small.

“So it went well?” I observed.

“Yup,” he said. “No problems at all. I didn't realize how how big a procedure it would be. I had general anesthesia and I was out for a while. But it's fine.”

“But get this,” he continued. “So I go home and Mary drives me and we pick up the pain meds I was prescribed. They prescribed Percocet, oxycodone plus Tylenol. That's pretty strong stuff. Do you know how many pills they prescribed? 50!

“So the first night I cut one in half and took it. I didn't like it; it made me feel bad, kind of weird. And I was on the phone talking to a friend and Mary said, 'You shouldn't be talking on the phone while you're taking those pills.'

“'Why not? I said. 'Did I sound weird?'

“'Yes, you certainly did,' she said. 'Stay off the phone.'

“So I only took one or two half-pills more, and you know what, just Tylenol seemed to do just as well for me. Why did he prescribe so many pills? I've got 48 and a half pills left, I don't know what to do with them because you're not supposed to flush them. What should I do, sell them? They're very salable. And somebody paid for me to get those pills, even if it wasn't me directly since I'm insured. Why did he do that?  Isn't this what's behind the whole opioid epidemic?  Isn't this the path to heroin?”

Well, yes; indeed, why did he prescribe 50 heavy duty opioids? It doesn't seem reasonable or prudent.

Well, think about our peds ortho friends looking for operations and avoiding office visits. In addition, think about how surgeons are paid for operations; they get a flat fee that includes payment for any office visits for the next 30 days. Clearly, it makes economic sense for them to avoid office visits after the operation is over, or even to avoid troublesome unpaid phone calls to the office. “Up and out, my man!”

From the surgeons' point of view, it obviously makes all the sense in the world to prescribe an ample supply of pain pills. It makes narrow sense, and so many surgeons are themselves so narrow. It's not for nothing that we know their motto to be, “When in doubt, cut it out!” Be decisive, and let's not overthink it, or some would say, let's not just think it through, period.

As I say, goddamn surgeons. Not all of them, but Jeff's, and so many. Where does the opioid epidemic come from? We know it's multipronged, we know that the pharma companies and the Sackler family convinced the medical profession that opioids were more effective than they actually are, and that if taken for pain they are not addictive, which is not true. But everyone knows by this time that this isn't true, and we know that prescribing them in quantity is not only unwise, it is dangerous and IMHO it should be unlawful.

By this time, no surgeons should be doing this. Talk about problems getting information out? Hell, you could read Time magazine and figure this one out. Jeff is not a medical person and he saw the problem immediately, as would any well-informed lay person.  It's not so hard to adjust - after my oral surgery last year my periodontist gave me, what, 5 Percocets or Vicodins in a little packet?

So I say, goddamn surgeons. You can set up new systems, you can pay doctors to do the right thing, you can do lots of things, but in the end you really shouldn't have to. In my disgust, I simply say, “Goddamn surgeons!”

Not that that helps anyone but me.

Budd Shenkin

Tuesday, December 5, 2017

Ideas On Sex And Language


Well, 'tis the Christmas season and all our thoughts turn to, well, the Russians and impeachment and afflicting the afflicted and comforting the comfortable, and since the Weinstein revelations, to sex. Or is it power. But to tell the truth, when Harvey's and Charley's and Matt's and the depredations of others came to light, I was already thinking about sex, although it's true that I've been thinking about sex pretty steadily since my penis got bigger and my scrotum became rugated, so nothing new there. Actually, maybe it was before that, since I had a girlfriend in first grade, although maybe actually that wasn't sex. I don't think it was, I think it was something else. I'm not sure what it was. I thought she was the prettiest thing in the world and I couldn't believe that she liked me too, but I didn't disbelieve it, either. I accepted it, Connie, number one. Still like anyone named Connie. It was simple then, it seemed; now I'm not sure about a lot of things.

One thing I am pretty sure about, though, is that America has always been batshit crazy about sex. Start with a Puritan beginning, add in Victorianism, Irish immigrants. Catholicism, the Jews and Italians and Southerners and slavery and what do you think you're going to come up with? America is batshit crazy about sex; how could it be otherwise?

Not that being batshit crazy about sex isn't somewhat of a universal condition. One reason I spent a year in Sweden in the early 70's was to find out what a reasonable and advanced society was like, not only with an advanced medical and welfare system, but with beautiful women who weren't conditioned to say no, as were the women I grew up with, before the American women led us into the sexual revolution. God praise them for that! What a step forward! Tell you the truth, I was so indoctrinated by my one generation removed Eastern European derived parents, and the general American culture, that I could never really believe that girls wanted it, too. And if they did, that scared me. The women showed it to me more and more as I got into my mid-20's and my thirties, unmistakably, maybe I had something going for me, but it was still hard to believe. Which are you going to believe, your mother or your lying eyes? “Close your eyes and think of England.” That didn't make sense to me, either, but what did make sense was that it was women who set the limits.

What was especially confusing to me as I grew up was the language. I loved anthropology and learned early that language can be key to understanding a culture. As with Eskimos having 50 words for snow. That's a pretty well-known and anodyne example, of course. I wonder what their word was for what I read was the common and accepted practice in that culture with long and cold nights and a spread out population, to lend a wife to a friend. That's what I read, anyway, in Anthro 1 in “Top of the World.” https://www.amazon.com/Top-World-Hans-Ruesch/dp/067173928X. And I also read that “Eskimo” is a term for the Inuit and Yupik peoples applied by outsiders. Common usage of a made-up word that applies to another people tells you a lot about dominance.

But I digress. Language codes our mindset, and a culture provides specific words as codes for ideas and values, which is why you have to learn a language to know a culture, to find the verbal shortcuts to a concept widely accepted, especially the proverbial “untranslatable word.” Maybe the first such Swedish word I learned was “logom,” which means “just right,” but actually more than that. “Logom” conveys as sense of quiet and peace and not moving and a sense of well-being, balanced and not too much of any one thing, as far as I remember it. Quiet appreciation and simplicity has a special place in an introverted and communal society.

Not long after learning “logom,” I learned “ut i skogan,” which is literally translatable as “out in the woods.” But in Swedish, again, that's not all it means. In that heavily rural country where even city dwellers have or would like to have a country cottage, or “stuga,” and a culture that accepts the presence and naturalness of human sexuality, “ut i skogan” has a distinct and universally recognized connotation of sexual congress. It is usually accompanied by a grin, and often used in conjunction with the term “Midsommar,” the celebratory day of the summer solstice and white nights, with obvious celebratory activities. Coming from the US it seemed like a different view of things to me, or maybe it was just my time of life and being in a foreign country. There are a lot of things I'm not sure about.

Like I'm not quite sure about lots of other cultures, as when one of the reasons the mutiny on the Bounty succeeded was the crew's discovery of Polynesian women, who it seemed didn't share a code of sexual activity with British women, at all. Probably it wasn't even just saying yes instead of no, it was maybe their getting the sailors to say yes. I wish I knew the words, they would be key; I wish I knew the history in detail, although it was probably censored.

What I'm getting around to saying is that I found out early in life that it was hard to talk about some sexual things in English. Early on, of course, we didn't have the words and we barely had the concepts. I remember in maybe 4th or 5th grade that my best friend Arnold Bernstein took me aside outside of Hamburger Haven across from Henry C. Lea Elementary School on Spruce Street in West Philadelphia and confided urgently that he had found out the word for what girls had. It was “cunt.”

I said, “Why is it called that?” It sounded like a hard and ugly word, Germanic, guttural.

“I don't know, because that's what it is,” Arnold replied. He was annoyed.; I was less appreciative of his titillating discovery and more linguistically analytical than he wanted and anticipated. So I learned that word maybe not in the schoolyard, but across the street from the schoolyard. Close enough.

Again, not quite in the schoolyard but close, on the Red Arrow bus taking us home from school in probably 7th grade, I made another linguistic advance in my sexual knowledge, if you could call it an “advance,” or “knowledge.” I told Richie “Boop” Reinhardt – Boop was portly and had made an unfortunate sound when a forward pass met his protuberant belly in PE, hence his nickname – that I had figured out which word was dirtier, “shit” or “fuck.” It was “fuck,” because after all everyone had to shit, you couldn't help it, but fucking was optional and you shouldn't do it. I can't remember what Boop had to say in return; maybe he accepted it as received wisdom. Who knows?

Of course, the schoolyard was only one source of knowledge. A couple of years after my conversation with Boop, my mother explained that babies came when a man and a woman “have intercourse,” and handed me two humorless books to read. In one there was a misprint and “vagina” came out as “regina,” and when I showed that to my mother there was a rather tortured conversation, examination of the book, and a frustrated maternal explanation that she didn't know how that happened but it was a misprint, she was pretty sure. I spared asking her if “vagina” was the same as “cunt.” I feigned general ignorance and was dutifully attentive. My Mom always gave me books, but it usually went better than this.

My father also attempted to fulfill his parental duty, making a trip down the hall to my room to inform me that I was now old enough to “impregnate” a girl and I should use a prophylactic. “How do I use one?” I asked. Frustrated, he sputtered, “You just use it,” and beat a retreat. To my relief and his. I was the oldest, and maybe it came easier with my brother and sisters. Hopefully. We never talked about it.

Years later, I had learned a lot more words and actions to go with the words, not as early as I wished, but eventually I got there. But I found that there was a still a problem with the words. In the early 1960's, it was still hard to come up with words for “doing it.” There were lots and lots of words, maybe as many or more than for “snow” up north. “Making love” seemed to be socially acceptable in some instances, but so etherial, with sentiments implied. “Getting laid” was also colloquial, and compared to “making love,” earthier and more urge-indulgent. “Going to bed” is too obviously euphemistic. I hadn't heard yet of “getting it on,” which has some idea of a party to it, maybe. “Fucking” still seemed like a dirty word. When I heard the Yiddish term “shtupping” for the first time, it sounded even more guttural and dirty than “fucking.”

And medical school didn't help at all. You would have thought it would, what with physiology, anatomy, OB-Gyn, psychiatry. Nope. Of course, I went to school in Boston, and maybe the New England environment was influential. In anatomy our team's corpse was a woman, and I don't think we leered, especially with a girl on our dissecting team of four, and the discussion of the anatomy was, well, clinical, with the course and relations of nerves, blood vessels, and the vas deferens. No mention of the clitoris except in passing, I think; what a shame. You would have thought that tracing the innervation of the clitoris and where the neural pathways went in the brain would be interesting, same for the penis, but somehow that landed on the cutting room floor.

The gulf between who we were and who we would be was probably best demonstrated by the class behind us at the traditional “Second Year Show.” In the scene depicting anatomy class, David Sachs, now a renowned transplant researcher at Mass General, regarded closely Grant's Atlas of Anatomy – the picture book – at arm's length in front of him facing the audience, and proclaimed as determinedly and loudly as he could, “Look at that picture of the cunt!” Not a natural actor, David wasn't adept at shading or nuance, but he sure got it out there. We looked sideways at the faculty wives; while they didn't look back at us, they seemed to take it in stride. “What boys,” they probably thought. I was pretty embarrassed at how crass it was, as I aspired to a more discreet and seasoned persona. But truth to tell, that was probably pretty much where we were, how we struggled, and also how med school presented it, the same way as we looked at the wives, out of the corner of the eye. There was still such a gulf between the schoolyard and the school, the schoolyard in the case of med school being the hospital wards, where there be nurses.

There was one med school exception, I guess. In our first year our class requested an optional Saturday morning class on medical emergencies. We made the case that as med students our peers and others expected us to know something about medicine, and with the curriculum as it was it would be years until we did. The faculty was tickled that we asked for extra work, so they arranged for it, and attendance was near 100%. It was a great class, one of the best classes we ever had, and you have to figure that the faculty loved being asked and volunteering, rather than their being required and our being compelled. You can imagine what they were thinking. Some were very serious, others perhaps less so.

One faculty member presented this case: a guy comes to the ER on Sunday morning and can't pee. An Xray is taken of the penis. The image of the Xray was flashed on the screen before us, we who had never looked at Xrays before. It was a mystery. The professor said, “Can you see what's written there, right in the middle of the urethra? Look at it. It says, 'Boston Hilton Hotel.'” Tittering.

“What do you think it is?” he asked. No answer from the seats, so he answered his own question.

“It's a swizzle stick!”

Laughter. But no further discussion. I imagined it was something erotic, but homoerotic? Sounded gruesome. No one was going to say anything about that. Imagine, in medical school. In the sixties, before everything changed. At least they could have mentioned how they got it out, if they're not going to discuss how it got in.

So, to revert to what I'm getting at, it seems that all these terms for having sex, only a couple of which I've mentioned, all had, every one had, overtones, innuendos, and connotations. And as I said, that's a linguistic tunnel into the culture. You couldn't talk about it without some sort of judgement.

And then came the sexual revolution. I'm not really sure what that revolution was. I know that before the revolution, like when I was about 14 or 15, I asked my friend Lucy if she would like to “do something,” and she told me her mother had told her that once you start you can't stop, and that was kind of it. I figure that the revolution was that women started saying “yes” instead of “no,” and sometimes it was actually they who were looking for “yes” from their male counterparts. But I don't know; maybe it's just that actual practice and formal expectations got closer together and people stopped sneaking so much. Like when our kids were in their 20's and we went on vacation with them they'd bring a girlfriend or boyfriend along and they'd share a room. I have to pinch myself that this is what we do now. Who'd a thunk it, for God's sake? I wonder if the younger, ahistorical generation appreciates the change. Probably not.

With the revolution came new language. It may seem modest, but it might be profound that a new term was introduced, “having sex.” What a gift, this term! The phrase of choice, usable in polite society, a term parents and kids can use with each other, a term usable in polite company, where it is now “polite” to talk about sex. “Having sex” is just clinical enough to be seen as common and natural, but not so clinical as to belong in the hospital. Adaptable to all situations, and it can be left to further description can add the nuances. It is basically nonjudgemental. Not that “fucking” or “getting laid” or “getting it on” will disappear; they have their legitimate uses. But if you want to talk seriously and realistically, there is now a pretty good basic phrase for it, and you can adumbrate as you will. Just in itself, it's possible that this neologism conveys a developing maturity to American sexual attitudes. As they said in Sweden, we just take it as a part of life. Or in France, “C'est normal.”

So far, so good. But when we see Harvey and Matt and DSK et al., we know the revolution is incomplete. There is so much more about sexual behavior to describe, and such a paucity of terms to use. “Power-sex” might be one new word. What lies behind it? It's old as the hills, we know that the original king of Saudi Arabia, Ibn bin Saud, had at least 40 sons. He probably wasn't fucking just for love, although who knows, maybe he had an extra big heart. We know about harems. I myself saw sex in Russia in 1994, when I was on an exchange program to St. Petersburg Children's Hospital #1, and we went on a weekend retreat. The chief of the hospital, Dr. Kagan, brought along his favorite nurse. That's just what they do in Russia, no fuss, they figure he deserved it, and she seemed happy enough. When Bill Clinton was condemned for Monica in the US, the Russian people said, “That's the kind of leader we need!” Cultures vary in how they view power-sex, but who knows, maybe Dr. Kagan loved her, she was very sweet.

We probably need a lot more terms to go along with the watershed changes that continue to cascade over us. I remember sitting in class as a senior in high school with a fresh-faced young male teacher with a nice white shirt and crewcut black hair was expostulating in front of the class, and my classmate Arlene whispered breathlessly, “I want to have him.”

I was a little amazed, being the naif I was, and whispered back, “How?”

Arlene said, “In every way.”

I figure Arlene was 17, perhaps on the mature side of 17, or maybe just 17. In any case, what about “student seeks teacher sex (SSTX)?” Wouldn't that help define a variation? Later on, SSTX in college leads to lasting relationships and marriages, along with broken hearts, but so does every kind of relationship. Multiple student relationships with one teacher might indicate teacher seeks student sex (TSSX),” maybe, although maybe he's just super-attractive. Leeann Tweeden-Al Franken situations could be “politically motivated accusation sex (PMAS)” perhaps. There are a lot of syndrome-naming opportunities available.

But there is one naming niche looking for a verbal inhabitant that I wish I could get a good naming handle on, and that's what we commonly call “sexual desire.” “Sexual desire” is close, but it seems too removed a term to me. Not that I'm looking for something guttural, but I don't want it romanticized and removed, either. “Having sex” needs a parallel term for the feeling that pushes us forward and lights up our eyes and fills our perineum. “Desire” doesn't do it for me. “Lust” gets one thinking of a green brute lurching through doorways. “Libido” comes a little closer to what we want, it describes something we can identify, but it's mysterious, foreign, and even psychiatric; too formal. There are lots of “L” words, stemming from the Roman belief that the tongue was key to sensuality: lascivious, lubricious, lecherous, etc. But pretty much all of them have a leering connotation.

Then there is “horny.” Colloquial, conveys an itch and a need, but the image comes from someone with horns, which would be a satyr, often green or red, spare, with a pitchfork maybe in my own imagination, prowling for any maiden he can find. Even if it's girls that are horny, there is something pretty crass about it, even if it doesn't have the masculine predation overtone.

What about “feeling those hormones?” This is a more indulgent view, used by those “more mature” who are supposedly “past that” and therefore “understanding.” An affliction that will pass, but can be understood. Still doesn't make it.

The term has to have some sense of insistence to it, and “desire” doesn't do that. There needs to be a term that would have better informed a mother of a teenage patient of mine who came in with a worry. She had found a sex magazine under her son's mattress. Her concern: she didn't want him to become a “sex maniac.” I could see from her face that she knew the term didn't quite fit, but it was the best she could come up with. I reassured her. “Carolyn,” I said, “How often do you think teenage boys think about sex?”

She thought a minute, and said, “Two or three times a day?'

I said, “Try every five minutes!”

I could have told her that a standard part of my questioning for a teenage male physical exam is, “On a scale of 0-10, how much do you like girls?”

The most common answer is, “11.”

To which I respond, “Right. That's about the normal intensity. Isn't it tough?”

So, in my view, we need a term here. I can't come up with a word in our current sexual vocabulary that does justice to the feeling and accepts it as normal. The best I can do is this: “sexual hunger.” It's not perfect, it still edges onto “voracious,” but is “hunger” judgmental? When you are hungry you need to eat, and you deserve to eat. Is sex so different? If you don't eat you waste away. I'd ask, what about sexual hunger, what if it is not satisfied? Psychiatry teaches us that it gets sublimated, sometimes to achievement, sometimes to anger and violence. You can even go further and talk about good nutrition and fast food, but I think I'll leave it there. What happens when sexual hunger turns into power-sex? What makes these guys do it when others who could, don't? It's not enough to say they do it because they can; there's some pathology that comes from somewhere, don't you think? Somewhere, sexual hunger not being satisfied could play a part. I don't know; there's so much I don't know.

Anyway, sexual hunger is the best I can do right now. We need something. If we are going to change our concepts, which we need to do, we'll need a new vocabulary. “Having sex” was a good start. Now we need more. On the plus side, it will mark progress if we see people groping for better terms and then using them. Actually, we do have a new term that edges into the realm of “sexual hunger,” although it is a solution rather than a definition. That term is “friends with benefits.” Two people both with hunger, wanting to satisfy it, understanding that it needn't go further than that. As a somewhat romantic person who once experimented with the concept but who seems to need affection to go along with the satisfaction of hunger, I'm wondering if this is just individual variation; some people like salsa and other don't. Or maybe if society changes, most people will like this salsa. Who knows?

Social progress is so difficult, isn't it? People like me, we're still caught in the past as we try to edge forward and have our kids stand on our shoulders and reach for the future. Inventing one term after another might be helpful. Certainly, we should be able to do better than the 50 words for snow.

Budd Shenkin