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

Monday, December 4, 2017

Stop The Sh*t And Give Us A Future


“Could you do it any better, big shot?”

How many open receivers can a quarterback miss for you to start complaining? After a while, you get to thinking that the answer to the question is yes, even I could do it better, and that's not my job, I'm just an obscure retired Jewish pediatrician from Berkeley. Or at least I could have done it better when I was younger. The older I get the better I was.

But when it comes to politics, and when you look at the Democratic Party, you know, it's hard to think I couldn't do it better. Their proposed rally cry is “A Better Way.” OMG. Former RNC Chair Michael Steele, opined, “I don't know what the Democrats battle cry should be, but 'A Better Way' isn't it.” Then he guffawed quietly.

No fucking shit. Following the Clinton era's clearing of the field – they wrecked havoc on the party, IMHO, even before the electoral malpractice for which Robby Mook and others should suffer eternal banishment – the Dem gerontocracy comes up with that. The Bernie-Warren wing isn't much better. I got a fund-raising call the other day from a guy running against Republican Ed Royce down south. I asked him, “What's your platform.”

He said, “I'm the progressive in the race. I supported Bernie Sanders. I'm running on economic justice.”

I gave him a hundred bucks, but while “economic justice” is true enough and would be a dog-whistle to bring out the Bernie base, it's just not a national winner. It's oppositional. It's just like Hillary's singling out every group she could except straight white people and saying, “I'm for you.” If you're “for” somebody, then you're “against” someone else. Ideology doesn't win elections, and to my mind it really shouldn't. Quality of the leader and the specific policies are better indicators of future performance.

So OK, big shot, you don't like “A Better Way,” and you don't like “Economic Justice.” So, what would you do if you could be influential and not just an obscure Jewish retired pediatrician (OJRP) from Berkeley? (And by the way, if you are going national, don't say “Berkeley.” Kiss of death. Try “Oakland.”)

I think you need to go both negative and positive, and I think you need two slogans. Against something, but then able to say, what would you do? The negative one: “Stop The Sh*t.” The positive one: “Help For You To Help Yourself.”

Stop The Sh*t” isn't too mysterious. And the asterisk is essential, even if a bit coy. It brings a smile to the lips instead of a snarl, and it names what needs to be named in a mildly scatological phrase. Maybe someone would alter it to “Stop The Crap.” But that's the message.

The challenge would be to name the shit because there is so much. It's tempting to focus on the Trump persona, but focusing on it the way Hillary did would be to make the same mistake twice. The crassness and narcissism of this injured and twisted person is obvious and repellent, but that is not something to be dwelled upon. You really don't have to. In person, a few laugh lines maybe, like “I hate to be unpatriotic, but I think the NFL should respect the issue of concussions.” Rather, I'd treat the electorate as a jury, and follow the advice of a successful lawyer friend of mine. He never drew the conclusions for the jury. He just marshaled the evidence, made the argument, and let the jury fill in the last sentence for itself. It gave them a sense of working with him, rather than being told by him what to do. Much more powerful. In Revenge of the Suburbs, people can draw their own conclusions on his personality and character, they don't need you to tell them.

But what they do need you to tell them is the details of what this Administration is doing, the horrible details one by one by one. Don't drill down on legislative failures the way the analysts do in diagnosing a “failed Presidency,” because Presidents can do a lot on their own, and Trump is doing so. Now that the massacre of taxes has occurred, that charge looses its bite, anyway. This list is so long, so long, as doctors say when looking for white cells in infected urine, TNTC – too numerous to count. But you can't be intimidated. Break it down, spin it out, in a measured way – here's what they are doing to America. The things that affect us all first – EPA, Interior, and if they really spike NAFTA the way they threaten, the price of flat screen TV's. And by the way, use of private airplanes to get to private residences – just throw the spice in for taste.

The tax bill deserves unremitting attention. What they're doing to the poor, to the middle class, to those who want to get an education. And then what they're doing for the rich. It's pretty easy to make the case, really. How much Jared and Ivanka and Don, Jr. will make from the tax bill. More and more on Louise Linton kissing dollar bills. Don't hit Trump directly, just let it seep in.

And then conclude, “Stop The Sh*t!” And keep laying it out, time after time. It takes repeated hits with the hammer to drive that nail into the wood. Keep at it. Stopping the sh*t is pretty much all you can try to do in 2018, anyway.


That's the easy part. The harder part is the positive part, which might not be all that necessary for the possible wave election in 2018. But more will be necessary in 2020, beginning but not ending with with a decent candidate.

Which, then gets us to the positive. If I ran the zoo which is the Democratic Party, if I were, say, Mayor of Los Angeles or Governor of somewhere, I would lay out one important role of government, “Help Those Who Will Help Themselves.”

You start with stopping the sh*t, of course. Back to Obama on the environment, back to Obama on health. Government needs to do things for everyone – we all breathe the same air, we are all dependent on the same environment in a small planet – and we need to work together. We also need a policy for things everyone deserves, like not to be hungry, not to be fearful, not to be homeless, and not to go without health care. But beyond those two bedrocks – the common good and the basic human rights in our rich society – we need to provide for the welfare of individuals and the welfare of our future society.

The true infrastructure of our society is our human capital. Yes, we need safe bridges and better internet communication, no question. Yes, we could improve our highways – driving through Oakland and on the freeways around here is a disgrace. That would create jobs in doing the work, although it's not clear how much economic activity the projects themselves would promote, probably not much. We need better bandwidth and laws that will provide better and cheaper digital infrastructure. These extensive projects are worth doing, but what we really need to do is to promote a human infrastructure that enables those willing to work to improve themselves to do so.

OK, education and training have always appealed to me. But think not only of the righteousness of the cause, but who it would appeal to. Those left out communities who voted Trump. Those more conservative Hillbilly Elegy people – voters – who don't want to give money away to wastrels. Anyone who is concerned about the kids, and anyone who is in middle age and thinks he or she could learn and improve. Anyone who understands where the future lies.

OK, it would cost money. Reverse the Trump tax cuts. Just reverse them. We can't reverse the huge wasted outlays of the Iraq War and the Afghanistan War – thanks, Bush-Cheney, Trump hasn't completely erased the memory of your horrible Administration – but with outlays for education and training come true growth, not the false growth promised by trickle-down.

Stop The Sh*t And Give Us A Future.” Nice ring to it.

Budd Shenkin

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 <http://buddshenkin.blogspot.com>, 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
SOAPM Chair

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.

SKB

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.

Sonia