Friday, December 31, 2010

The Lame Duck That Lost It's Limp

It was heartening and amazing to see the Lame Duck congress pass a comprehensive tax program for the next year (however compromised by economically unnecessary but politically necessary giveaways), repeal Don’t Ask Don’t Tell, and pass the New Start treaty. After the goddamnest biggest case of legislative constipation anyone can remember. Everyone is asking, why should this be? Lame ducks are usually the weakest legislative animal in the barnyard.

I don’t know either, since I’m not close to the situation, but I do have some thoughts.

Most important has to be the Obama shellacking. Since the Republicans had gotten scorched two elections in a row previously, this evened the score, and the Republicans could now let things go through without seeming weak. They had just won, they had their honor back, so they could compromise from a position of seeming equality. Politically, their Just Say No strategy had won them the election, so there was little to gain by continuing. By the next election no one will remember the Lame Duck much, and a new electoral strategy will be in place.

And besides, both DADT repeal and New Start were not only popular with the public, but the military were strongly behind both, every past Republican Secretary of State and Dick Lugar were strongly behind New Start, so get it out of the way! Get your own new start.

Kyl and the Turtle (McConnell) had got themselves caught out there on the wing, playing the old game, so for them it was best just to vote as if they still believed what they had said (which they couldn’t have, really), and again, get it out of the way.

I wonder, however, if there isn’t something else happening, and some Republican sensibleness now coming down the pike. There might be a generational split developing in the Senate, as revealed by the current maneuvering to redo the rules in the next Senate – make the filibuster a talking filibuster, reform the initial motion to proceed to discuss legislation, and the placement of secret holds. The younger group (see Tom Udall) wants reform – they want action in the Senate. The leadership on both sides would lose some of their power with these reforms, and so are reluctant to proceed. But the Senate as a body is held in derision by the country as a whole at this point, so even the leadership must be sensitive to that, and maybe there will be some reform.

What about the upcoming term – more like the last term, or more like the Lame Duck? I’m an outsider, so I don’t know, but I suspect that Obama has spent two years learning hard lessons, and he will come back more aggressive, more teaching the country and less making a few lofty speeches that open him to charges of elitism and arrogance. I also think that Just Say No will not be much of a strategy from here on in. So, my prediction would be that there will be action. The President proposes and the Congress disposes. Success will depend on what is proposed. We’ll just have to see.

Budd Shenkin

Friday, December 24, 2010

Tales of a German Urologist

Urology is not where one usually turns for wisdom – humor of a certain sort sometimes, but not wisdom. Still, within humor there is often wisdom, and in a package that is easy to accept.

Enter my colleague Bernd Schmidt of Pleasanton. A tall man with a craggy face hidden by a rather sparse beard and ever-ready grin, he has a strong German accent that demands close attention to understand him. I really don’t know him that well, but I thought he introduced himself as “Ban,” so that’s what I call him at the doctors’ lunch table at ValleyCare Hospital, be it nickname, the pronunciation of Bernd, his accent, or my poor hearing.

Each specialty in medicine has its own stereotype, and as with most stereotypes, there is a core of accuracy. I once introduced myself at a party of lawyers in the City as a pediatrician, and was told that “you guys are all alike.” Yup, I could have replied, and so are lawyers, as typified by that remark by you, asshole.

But I digress. Internists are removed, cerebral or pseudo-cerebral, not the warmest buns on the table. Surgeons are cowboys who can’t wait to cut but can’t think well or broadly. Orthopedists are strong as an ox, and twice as smart. Urologists – well, urologists. They have a very down to earth attitude, shall we say. My med school classmates told me to prepare for a unique experience in my one-week Mass General urology rotation. They were right. My residents gloried in making rounds while smoking cigars, inquiring of their patients amid their smoke, “How you doin’?” Actually, It was refreshing not having to deal with the poseurs the MGH was rife with.

One of my classmates was interviewing for a surgery residency in at MGH with George Nardi, who had some post in the department. He waited for a while for Nardi in his hospital office, a converted exam room. Then Nardi burst in, hustled over to the sink, pulled out his penis and pissed right in the sink, with a gasp of relief saying, “Sometimes you just gotta go.” Nardi should have been a urologist.

My colleague Ban has a typical urologist get-rich scheme, inspired by the plastic surgeons. He wants to use Botox injections to take the wrinkles out of the scrotum. “Wouldn’t they be beautiful?” OK, Ban, good. You’re a urologist, all right. Wish you smoked a cigar. Maybe your scheme will work in San Francisco, who knows?

Ban had two stories yesterday at lunch. He related that in Germany you never, ever, marred the bed sheets of a patient. The German passion for order and cleanliness prevailed. So he was shocked when he came to America in training and saw that the urologists on rounds routinely used the bed sheets to write on as they made rounds. My MGH urologists were too busy with their cigars to write on sheets, but it did seem right in character.
But Ban said it didn’t always work out too well. A few weeks into it he was standing at the foot of the bed as the urology staff was gather on each side of the bed, discussing the case over the patients supine body, his head sticking out from under the sheets as he listened. The urologists drew pictures on the sheets, depicting the anatomy underneath. But what they didn’t notice was the patient. As they drew and discussed, “Then we’ll cut here, and then here, then pull this together,” and so on, the patients face became paler and paler, visible only to Ban at the bottom of the bed, as the others were in heated discussion. Finally, as they agreed, “Right, this is just where we’ll cut,” the patient sat up and vomited everything he had all over the bed sheets, the pictures, the pens, their hands, and their cuffs. Urologists.

But on a more serious note, Ban has another side to him, a really lovely and understanding, which is to say, perhaps a non-urological side. I told Ban that I had always been fascinated by Germany, but that as a Jew I had of course ambivalence, to say the least. Still, my father had been one of the first to buy a VW in the United States, on the grounds that it was pretty cheap. So my family heritage enabled me to be somewhat dispassionate. Ban is from the Hamburg area, and I said I had heard that the real rapid anti-Semitism was in the south, and especially in Austria.

Ban agreed. He reflected that as a German medical student he could change schools each semester within the German community, just so long as he passed all his requirements. So one semester he decamped to Vienna, where he rented a room in a house where the only TV was in the landlady’s living room. So he was watching TV with her one evening and there was a documentary of some sort about the holocaust, and Austria’s experiences. His landlady denied that there was much anti-Semitism in Austria. She said, “All that never happened here in Austria. It’s a lie. This movie must have been made by some Jew.”

Ban has remembered this story a long time. Reminds me of how one of my very favorite authors, Alan Furst, has never written about Austria and Vienna. “Just never wanted to do it,” he said at one of his readings I attended. Probably one of the cities I won’t visit, either.

It’s good to eat In the doctors’ dining room. You meet the most interesting people. Even urologists.

Budd Shenkin

Sunday, December 12, 2010

Tales of Worker-Management Cronyism

The auto industry, civil service, and our old friend health care – three separate very troubled American industries. But if you look at them critically, it seems to me they have a certain sameness, which then makes me think they might reflect a more general American problem.

I have recounted the tale of the auto industry before (see Paul Ingrassia’s book, Crash Course.) The auto industry was a major success of modern industrialization. Three large companies emerged with one large union. The UAW wrested very high wages and benefits from employers, extensive and strict work rules, company pay for union organizing jobs, and a job bank where workers were paid for years not to work. The success that liberals now celebrate was that, thanks to union power, line workers entered the middle class. I, too, like to see people do well, but in this case the collateral damage was really unacceptable.

As the UAW thrived, management didn’t do its job. They not only caved to the UAW, they also pursued their own slothful and self-indulgent agenda. The managers were not unhappy to see workers’ pay improve, because they simply applied a multiple of that pay to compute their own. They exerted no quality and efficiency discipline, they continued to populate their own managerial ranks with the mediocre products of local feeder educational institutions, and they passed costs onto the public. When Japanese competition appeared the American auto industry had so little muscle and so much fat that they simply went lifeless, dead by their own hand and evil constitution.

We are also now facing a crisis in civil service. I don’t know how it arose, but the civil service deal has been a tradeoff of lower wages for better benefits and security. The civil service was supposed to be quiescent and not union organized. The deal started to unravel when unionization was allowed. We are now faced with civil service workers who retain their security, but who now have generous pay and benefits while they work, and pension plans that will soon bankrupt the country. Civil servants can retire after 30 years of service, sometimes even earlier, which lets many retire before they do in France or Greece, at nearly full salary. Not content with that, many have plans whereby they get a percentage, sometimes 100%, of their highest yearly salary. They can accrue vacation time and other bonuses until one year when they get a large spike of salary, and that’s the base they figure from. These retirement benefits are generally unfunded. That is, they need to be paid for by others than those who granted the benefits, because they were future benefits.

Who was on the other side of the bargaining when these deals were struck? Civil servant managers and politicians. The problem was that as soon as you have unions, you have political campaign contributions – the best example in the world being the California prison guards union. In addition, city and county managers responsible for recommending solutions to the political powers are similar to the auto managers. The managers’ financial fate is aligned with that of the other workers, rather than opposed. So, we have had managers who will benefit by caving into union demands, and politicians who can curry present favor in exchange for someone in the future having to deal with it.

As a result, we are in the soup. Unfunded obligations simply hang over us. As with auto management and workers, politicians and civil service workers act more like cronies than adversaries, and the public takes it in the neck.

Finally, the health care industry also has common elements. Hospitals drive health care costs. Hospitals can compete with each other for business, but if they cut costs and become more efficient, what have the managers really gained? The way health care is set up, a lower cost provider doesn’t really gain anything. Because patients and referring physicians do not pay much of the cost directly themselves, it is better for a hospital to be fat with patient amenities, and fat with rich physician “directorships” of various services and departments, and fat by giving into the relentless demands of the nursing unions and SEIU. A larger hospital budget translates into larger manager salaries and perks. Let the pubic pay, now just about to the breaking point.

These three industries seem to have the same dynamic – lack of competition to discipline the managers, and a resultant cronyism between management and workers to the detriment of the public. It would be nice if managerial professionalism led the managers to stand up for the public interest, but people being people, that doesn’t happen. Would that there would be the equivalent of the Hippocratic Oath for professional managers and politicians, but that doesn’t even work consistently for physicians.

In our mixed economy, when a market isn’t working, government is supposed to intervene, and either make rules to create a market that works, or to enforce an administrative solution. You can see how that didn’t work in the auto industry, is not yet working in health care, and government is itself the problem in civil service. My own sense is that government could be made to work in all three instances if we had the will and wisdom. A stronger government more impervious to business influence could adjust cases one and three, and governmentally appointed independent commissions could have warded off the civil service disaster.

Government needs to be better, smarter, more professional, more independent -- just better. We need leaders! We don’t need Plato’s guardians, but do need big guys, smart guys, aggressive guys on our side. Guys like my hero, Elizabeth Warren. We don’t need bigger government, we need better government.

Which is why I support the Goldman School of Public Policy at the University of California, Berkeley, my alma mater. Maybe fine professional schools harbor the long term solution. We should think up a professional oath for them.

So what do we do in the meanwhile? Yesterday my wife and I went shopping in downtown San Francisco. It was a sunny day in the low 60’s with happy crowds. We walked in the sun, we ate lunch, the fries were really good, we laughed. Life goes on.

I was buying baubles at Gumps, where we had somehow wound up, and Ann took little 10 month old Lola outside to wait for me. She is a happy baby, but this time she sat down on the sidewalk and cried. As Ann picked her up, a nice man on the way into the store said wryly, “I wish I could do that, sit down on the sidewalk and cry!”

Sometimes, so do I.

Budd Shenkin

Wednesday, December 8, 2010

Health Care Costs

In response to my last post, from a colleague:

Hi Budd,

We all have our stories. I had radiation therapy for cancer. 12 weeks, 15 minutes a day. The charge was $3500. Per day. That’s 60 days treatment at $3500. $210,000. BCBS paid at 100%. I am lucky to get 80% on a $85 office visit.

What is going on here, with these costs? As I've said before, let's forget utilization - what about prices? There is just no curbing them at present, and to my mind no prospect of such. Here in the East Bay, the rising cost of health insurance, which is a consequence of these prices, is simply driving more and more people to Kaiser, which can control its prices. This exodus from private insurance reduces the pool of private patients at Sutter and elsewhere, who respond by raising prices even higher. This is what is called a death spiral.

Nothing goes on forever, so there will be an end to it, but it's hard to see right now what that end will be. I wish I could be brilliant and see it, but I'll leave that for the often-wrong economists. The idea of ACO's, like HMO's before them, is for a group of providers to be able to look at a group of patients and plan rationally for their efficient care, saving money and distributing it to themselves and kicking some back to the government, but it's a speculative program and will take some time to take effect. In the meantime life goes on, trends continue, and anti-trust is silent.

Budd Shenkin

Tuesday, December 7, 2010

Health Care Costs - What Hospitals Charge

So, where does our health care money go?

My wife has diabetes and was urged by her doctor to attend a series of self-care classes at our local hospital, part of the Sutter chain. First, she had a half-hour individual consultation. Then she attended a series of four 2-hour classes in a group of 6 or 7 patients on Wednesday afternoons. She was told that they "would bill Medicare." The classes were taught by a nurse.

Billing for the first visit, $280. Billing for each class, $400. Total, $1,880.

Seems like 6 students in a 2 hour class taught by a nurse, billed out as $2,400, or $9,600 for the set of 4 classes, might cover the salary of that nurse plus overhead - even at the inflated rates of pay for nurses at this hospital.

By mistake they sent the bill to our old insurance company, which excluded $470 of the charges, so the private insurance charge would be $1,410. Some hard bargaining there....

This is the same hospital that charged $13,000 for an abdominal CT scan.

So, tell me whether or not we need health care reform???? The market, she not working too well. But, alas, our just-passed health care reform will not touch this kind of billing at all. Health care reform? Not really - mostly enhanced coverage and money for clinics and some experiments in research and organization in health care that gores nobody's ox. A disgrace, really.

Budd Shenkin

Monday, December 6, 2010


I have been having major difficulties with the Obama Administration. I really hate to blow in the wind, although truthfully, like the majority of people (by definition!), I catch myself doing that all the time. A careful reader might remember that I blew against the wind last spring when everyone thought the Democrats would do poorly in the fall elections. I bravely stood up and said, “Not so!” I predicted that Obama would rally the troops, show leadership, and pull a Roosevelt 1934. So much for spitting into the wind.

I now find myself blowing with the wind instead of against it. I conclude that Obama is not much of a leader. He has a very small coterie of old friends – who the hell is Valerie Jarrett, and what is she doing in the President’s inner circle, I ask you? – and as my wife says, he really misses Ted Kennedy, who could have steered him right, who knew how to fight and when to cooperate. As Krugman says, he bargains with himself time and time again. And who knows what he really stands for? It’s just not clear. The policies of the Justice Department seen only to veer somewhat from the Bush years, and not bringing to justice the CIA people who destroyed the tapes is just ludicrous. It has become a nation of people and not of laws.

If I had been him, I would have been on TV every Saturday morning after cartoons, up there with a cabinet member or a chief adviser, questioning him or her, making the points about what we are trying to do, how we have to save the system, although we hate to reward people who brought it down. How we need to reach out to the soldiers in the economic field, “Main Street,” and take care of that aspect simultaneously, and how hard it is to do. How we have to find “shovel ready” projects and make sure that we are not shoveling shit, as governments are want to do. I would have gone into it in detail, and not worried if we looked like it was difficult to grapple with – let people feel the problems along with us. That’s what he promised to do, and it wasn’t a bad promise, either ideologically or practically politically. But he wilted.

Maybe I’m wrong. Maybe this “let’s all get along” President will yet turn the tide to civility. Maybe the Republicans, their honor restored by an historic victory, will now be able to deal with a Democratic President without seeming craven. Who knows? Just when I turn and blow with the wind, maybe that’s the capitulation the market was waiting for, to suck me in before it turns.

But here, look at this from the Incidental Economist blog [I have resisted a blog quoting a blog for a long time, but here I am, with the wind again! Oh, my.] The Obama Administration caves yet again:

Obama’s quiet $49 billion gift to America’s Health Insurance Plans
Posted: 06 Dec 2010 01:00 AM PST
America’s Health Insurance Plans (AHIP) is a trade association representing private health insurance companies including those that operate most Medicare Advantage plans. AHIP opposed the Affordable Care Act (ACA), spending heavily on ads that criticized the President and Democrats for supporting cuts in Medicare Advantage payments. These cuts, which Austin and I have shown would fall mostly on plans, not on beneficiaries, were scored by the CBO as worth $136 Billion over 10 years. They are the backbone of the financing for expanding coverage to the uninsured and one of the few real cost control measures in the law.
In the mid-term election the Democrats fared poorly. Many Democratic candidates had difficulty explaining their votes in favor of ACA, particularly to elderly Medicare beneficiaries concerned about Republican and AHIP charges that it will cut their Medicare benefits. On Veterans’ Day, just 8 days after the election, the Obama Administration quietly released a new regulation expanding quality bonuses to Medicare Advantage plans that receive only average quality ratings. Julie Appleby of Kaiser Health News reported a few days later that some analysts interpreted this as a gift to the plans worth about $1.3 billion over 3 years ($5.3 billion over 10 years). Austin and Brad Delong both expressed concern that this could be the beginning of the political unraveling of one of the few cost controls in the ACA.
How could a $5.3 billion give-away make a meaningful dent in $136 billion in savings? It couldn’t. But the $5.3 billion figure is probably wrong. A more realistic estimate is almost ten times larger.
The original quality bonus program written into ACA targeted bonuses to plans receiving 4 or 5 “stars”, representing approximately 23% of enrollees according to Brian Biles and Grace Arnold of George Washington University who analyzed the data last April. The new regulation will grant bonuses to plans receiving 3 or more “stars”, representing 84% of enrollees (3.7 times as many). Biles and Arnold estimated the cost of the original bonus program at $1.4 billion per year as long as plans don’t respond to the bonuses by improving their quality ratings. The details of the expanded bonuses have not yet been released, but if we assume the new program will be similar to the old one, we can make a rough calculation of the cost: 3.7 times $1.4 billion is $5.1 billion per year. Accounting for expected cost growth, that’s a $49 billion difference over 10 years. If plans respond to the incentive, the spending will be higher. That’s a heck of a stocking stuffer.
Do you remember when the President stood firm against withering opposition last year and rallied his party to achieve an historic expansion of health insurance coverage while insisting that the bill be fiscally responsible and reduce the long run deficit? Sure was inspiring. If I were one of those members of Congress who did the right thing, voted for the bill and just lost my seat, I don’t think this latest example of the President’s generosity toward his adversaries would lift my holiday spirits.

Budd Shenkin

Monday, November 29, 2010


Is there anything coming up with the Wikileaks that is surprising? I can’t find much at all.

It has already been widely reported that Arab states want the US to get rid of Iran as a nuclear state. What we get from Wikileaks is the names of the Arab leaders, and that’s all.

The fact that Putin and Berlesconi have some common predilections? Trivial and gossipy.

The fact that the Obama Administration reached out to Iran but expected those gestures to fail, and had alternative plans for tightening and extending anti-Iran measures? No surprise.

The fact that no one trusts what Iran says? Now, that’s news!

Yemen complicit with the CIA? Surprise!

Karzai paranoid? Already public knowledge that others think this about him.

Karzai’s brother working for the CIA? Well reported.

Pakistan has poor leadership? Please. ISI is close with the Taliban? Come on, how could that be?

That the US would like to see North Korea implode and join South Korea? Nice they’d like to see that – the essential weakness of North Korea is not news.

The Obama Administration pulling the anti-missile installations under Russian pressure, and perhaps getting cooperation in return? Well reported.

In fact, I wonder if there isn’t a lot of dis-information in the leaks. For instance, is Israel as much of an independent actor as it is reported to be? Isn’t that exactly what the US would want to portray – “Well, you can trust us, but we don’t know what to do with the Israeli’s.” Good cop, bad cop.

What is embarrassing is the reaction of the US diplomatic community. They seem foolish and ingroupy – they are invading our space! How can anyone trust us now? They have crashed our little game! Not much of it seems so serious and intelligent, tell you the truth. But now they react so predictably – OK, people in the government, we’re going to shut it down, OK? Let’s be careful!

Who trusted them before? It all seems like crap to me. It’s scary to think again about how limited our “leaders” are. Sure wouldn’t want to make me join the Foreign Service….

Budd Shenkin

Saturday, November 27, 2010


This is a post about education policy. New York Times columnists David Brooks and Tom Friedman, among others, insist that we need to concentrate as a nation on improved educational achievement, because that’s what jobs are requiring. Everyone knows our numbers suck, and Tom and David want us to concentrate on education, and they think parents need to be proactive with motivating and disciplining their children. This is the future, they say, and if we are inattentive, our nation will suffer severely. I agree.

There must be many, many reasons our achievement numbers suck. The outrageous proposition that education is a jobs program, propounded by risk-adverse teachers unions, is an attractive culprit, because they set self-interest against the public good. But I’m wondering if some of the reason lies in what I call the Warm-Heart/Cold-Mind dichotomy (WHCM, which sounds like a radio station.)

WHCM was presented to me most cogently in medical school. As a young liberal, with two classmates I started the Public Health Club, and Dean Robert Ebert assigned Dr. Dieter Koch-Weser to advise us. For our first session he assigned us a couple of articles that presented a dilemma of public health policy that, truthfully, I wasn’t ready for.

It is heart wrenching to imagine or to see babies and children dying from malaria. Some projects eradicated malaria in local areas. What happened when they stopped this suffering? Well, the ultimate results were not so great, it turned out. Evil though it was, malaria kept the population in check. Absent malaria, overpopulation ensued, and the suffering was worse than ever. I don’t remember the details of what actually ensued, but take my word for it – the cure caused more suffering than the disease.

As I say, I wasn’t ready to handle the conundrum – what does one do, then? Koch-Weser didn’t have any specific advice on that either, as I recall. But it was a memorable session – after all, it was 45 years ago and I remember the moral turmoil and policy confusion it caused in me.

Other liberals were confused, too. My Public Health Club co-founder, Carol Wolman, who had actually been to Africa, said that African doctors treated those in the cities and didn’t do public health, which would save ore lives, because they were short-sighted, and couldn’t resist taking care of the sick person in front of them. It could be a case of WHCM, but she probably neglected the fact that Africans who got to be doctors were from the wealthy class, and went back to treat the wealthy. Just a liberal confusion, I guess, with “mirror thinking” that others think the way we do.

In Africa in the late 70’s and early 80’s there was mass starvation. The response was food airlifts. Wrong and fuzzy-thinking, said an article in the New York Review of Books. If you save the children and don’t provide for more food production domestically, it will just happen again and be worse and create even more suffering. As it happened, I think there was more food production, and now AIDS has taken care of winnowing the overpopulation problem. Maybe the article was wrong; maybe too cold hearted and not hopeful enough that the future would actually experience advances that could support a larger population. Or maybe not.

Then as a pediatrician I saw what happened in the Intensive Care Nursery. Severely premature babies had literally a million dollars spent on each one, with profits to the hospitals that built the biggest and best ICN’s, and large salaries for the neonatologists and many pediatricians becoming neonatologists, hundreds of thousands spent for later rehabilitation, only a rare baby without deficits..Triumphs, yes, but lots of failures, and immense total costs, and resources drained from other, less dramatic areas.

So, to education policy. Years ago, they closed our neighborhood, fully-integrated school because it was “too good,” literally. The School Board made it into some kind o a magnet school where no one from the neighborhood goes any more, and where it doesn’t attract envy for being too good. God forbid someone should achieve.

Last year Berkeley High proposed that many math and science AP classes be abolished, the resources to be scattered to the underprivileged and underachieving groups in an unspecified way. It came within a whisker of being passed.

More generally, how much money are we spending on remedial education? A lot. Any Nobel Prize winners emerging from that expensive enterprise? If I were the father of an autistic kid I would certainly appreciate the tens of thousands of dollars that the school districts would be paying for one on one treatment. I can understand the power of the autism lobbying groups who want their children cared for. But still.

Have you had a friend or relative become a teacher for the developmentally delayed (aka, retarded)? A noble enterprise, to be sure. But the apogee of civilized achievement? At what opportunity cost?

So, you can talk about the weakness of the parents who do not value education for their children and make them turn off their cell phones and study instead. You can talk about the importance of caring for each child. You can say that a society is measured by the way it treats its weakest members. As a pediatrician I have a certified warm heart.

But as a cold-hearted public policy analyst, seems to me we most urgently need to support our best, and our next-best, and our third-best, those with the highest potentials. We should be able to do all of it, true. We spend too much on Pentagon waste, true. We could redo our entire educational menu and upgrade the quality for all, true.

That ain’t gonna happen. India isn’t going to do malaria control and agricultural reform and population control and educational upgrade all at once, and we’re not going to do defense reform, governmental efficiency upgrade, health care priority reform, and educational reform all at once, either. No long bombs, only three yards and a cloud of dust. So, when Tom and David tell us where our priorities need to be, are they going to say anything about our caring for the developmentally delayed and the autistic, or are they going to concentrate on getting parents to turn off the TV’s? Are they going to talk about liberal, warm-hearted groups that form what an objective observer would call special interests?

Back atcha, guys.

Budd Shenkin

Saturday, November 20, 2010

The Giants Win the World Series

I don’t believe in God, certainly not in the old-fashioned sense of a Man on a Throne. But I do think God is a pretty good heuristic.

“Heuristic” means to me “as if.” You don’t really believe this is so, but it’s useful to believe it. Now, that’s not Pascal’s Wager, which tells us to bet on the existence of God, because if God does exist you will be rewarded, and if he doesn’t, well, what have you lost? That’s not a heuristic, that’s a cost-benefit analysis.

Here is a good example of a heuristic: if you play the stock market, it is useful to believe that there is an “operator” who is manipulating the market to draw you in and take your money. There used actually to be operators, but they don’t exist anymore, or so we are told. Still, the market acts as though there were one. It goes down to scare you, and then down again, and then again so you finally sell your stock, and now that the operator has bought your stock at a cheap price, up goes its price with you on the sidelines in frustration. The mythical operator has struck again.

So, I don’t believe in God. But it’s useful to think that “God will provide.” You can’t plan everything, you can’t be sure of everything, sometime you just have to take a chance, move to America and leave the Old World behind, and think that “God will provide.” It might be you yourself who will provide, or the Massachusetts Indians, but it’s useful to think of God up there to help you.

And so it is with baseball, itself the holy of holies. Not that “God will provide,” because anyone who has grown up rooting for the Phillies, the A’s, the Giants – in fact, I guess everyone except the Yankees – you know that God will not in fact provide. You will lose and lose and lose, and be drawn into thinking that this might be the year, and then you will lose again. So I have always figured that if our team is not mathematically eliminated in September and the games still have even theoretical meaning, it was a good year.

It helps to remember Job, and believe that sometime, maybe at an unexpected time, the plagues will finally relent. Maybe. And that great turn of your luck will not depend on any particular virtues of yours, but it will simply be a gift from a heuristical God.
And so it was this year. There was no reason to think this year would be any different for the Giants. None. Excellent pitching, which they had had before. A lack of bats, severe, I thought. So all through the year GM Brian Sabean brought in people and tried them out. Some worked – Aubrey Huff at first – and some didn’t – Bowker in left. Most famously, the “accidental Giant,” Cody Ross, became a Giant off waivers only because the Giants didn’t want him to go to San Diego. And then he comes up with five homers in the playoffs. It’s skill on Sabean’s part, and on manager Bruce Bochy’s part, and luck, and chance, and happenstance, and you could say it just was the fact that God decided to smile on you, for no particular reason that we can figure out.

For me it was particularly amazing, since my beloved brother Bobby is a die-hard Phillies fan and season ticket holder. While the Giants were making their amazing run at the collapsing Padres in September, when it seemed that God was just determined that they should win, Bobby and I faced the prospect of rooting against each other. After 34 years in the Bay Area and being partners in Giants season tickets I am acculturated – the Phillies are my second-favorite team. (Actually, if the A’s recover, that might not be true – but they will definitely be my second favorite team in the National League.) So the best we could hope for would be that the Phils and Giants would not face each other in the first round although the odds were against it. But fie on the odds – God provided, and they faced different opponents in the first round, so we could root for each other’s team, and both teams won. Voilá!

Then our Giants were on to the powerful Phillies, with their winning experience and very solid lineup, featuring the great Shane Victorino (inside joke – he’s from Maui and has a featured box on the Maui News sports page every day, really funny home town boosterism, “Victorino and Phillies advance to League Championship series!”)

How was every desire coming true? Where was this coming from? How was it that every move worked out? The new players produced, Wilson kept saving games, Uribe hit an 8th inning homer to beat the Phillies. How did we beat their great pitchers? Ryan Howard looked at a third strike when he should have been protecting the plate. Bobby and I communicated carefully with each other, since we each knew where we stood. From not believing they could catch the Padres, to the World Series. Why was he smiling on us?

God smiled again. I was due for tickets to the 6th game but my partner Jim wanted to trade his 1st game tickets for my 6th game. It’s a deal, Jim!

Ann, as my wife, always has first call on the tickets, but usually says that someone else will appreciate it more and gives them up. But this time I prevailed on her to go with me, to both the Phillies game and World Series #1 game against the Rangers. While she was reserved for the Phillies game, she said it was great. Then for WS #1 the reserve evaporated. It was a wonderful night. Balmy. Mellow. Joe Montana was sitting two rows ahead of us across the aisle. Other SF notables popped up here and there. We belonged there; these are our seats, our city. Tony Bennett sang I Left My Heart in the second inning because he was late – took Muni to the ballpark. 83 years old, but the voice is there. It was November, but it was in the 60’s, calm, comfortable, perfect, the whole night. (The next night it was Steve Perry from Journey singling “Lights” about the City, and when they stopped playing that, the crowd kept singing. A sports writer from Texas who repeatedly trashed the Bay Area had to write as he visited here, “I take it back. I love this city.”)

Ann said, “Look at the sky!” It was remarkable. It was like slate, but a bit uneven, blue-black, some parts darker than others, but not moving at all, perfectly still. Aaron, one of my partners with the tickets, turned around and said, “Look at the sky.” Look at the sky.

It was tight, and then the 5th inning happened. We kept scoring and were a couple of runs ahead. Then Uribe hit a three run homer to push us way in front. Everyone around us looked at each other, gave high fives, and then literally said stopped and said to each other, “My God.” There was singing and I was dancing as Ann laughed at me, and laughed with everyone else. In the 7th Tony Bennett sang God Bless America and so did we.

I’ve heard that hospitals are the modern equivalent of medieval cathedrals, but now I think it might be sports stadiums instead. At the ballpark we were one, knit together, being blessed. How else can you look at it? It was just a gift from a heuristial God, and it was our job to take it, to accept it, to appreciate it, to be blessed with it.
It’s probably the best sports experience I’ve ever had, in a lifetime of watching sports. And blessedly, my brother Bobby was good enough to send me a text that said, simply “congratulations.” The Phillies have had three great seasons, and Bobby has been through enough to know that when your games still mean something in September, and you make it through the playoffs to the second round, you, too, have been blessed by a heuristical God.

What a night, what a series, what a set of playoffs, what a season, what a sky, what songs, what a crowd. What a life.

Budd Shenkin

Thursday, November 11, 2010


My wife Ann is never late. I have learned a lot from her. And she has learned a lot from me, about how to tolerate being late. Opposites attract.

But when it comes to going to the airport, she wins. In fact, she has won so much that I try to be very early even when I’m not with her. We don't just make compromises when we get married, we change.

So today we left super-early for the San Francisco Airport to drop off Ann, Sara, and nine month old the magnificent Lola – up at 6:30, out the door at 7 for the maybe 40 minute drive to SFO for the 9:15 flight. We almost made it; probably would have if we had left 10 minutes earlier. Just not quite.

Maybe you have to feel sorry for the guy afterward, but most people had trouble ginning up sympathy at the time. KCBS reported that a heavy set guy in his 50’s in white pants and a tank top, with his 16 year old daughter in the van where he had apparently been living, decided to express his frustration with his straying, divorcing wife by calling KCBS, saying he had a gun and a bomb, and that he was going to stop traffic on the upper deck of the Bay Bridge, which is of course our route to SFO. He succeeded even if he really didn't have the gun and bomb he said he did. He was on the suspension span, we were not far behind on the East Bay side of Yerba Buena Island. We stayed on the bridge not moving for one and a half hours; people got out of their cars just to look around, look down at the Bay, and kind of look at each other. That's what we did, too.

It was the KCBS story of the day as we listened to what we couldn't quite see -- the man threatening to jump, being talked back onto the bridge, handcuffing himself, and the bridge lanes finally opening up, just in time for us to arrive at SFO at 9 AM, and the flight to go bye-bye without wife, step-daughter, and magnificent grand-daughter. They rebooked on the 2 PM flight and faced 5 hours in SFO with a magnificent 9 month old who loves to walk holding on to two fingers a few inches to the side and above her head. Much better than napping. Oh, joy!

We did well, even though leaving early was supposed to prevent this. No one panicked, although it was gruesome to try to reach United Airlines on the phone – could only get someone in India who couldn’t understand our telling her the number of our tickets, much less call ahead about our predicament, etc. Telephone answering trees are carbuncles on the body of the modern world. "Which of the following services best describes what you want...." How about, "none of the above, we're sitting on the Bay Bridge not moving?" Sitting there, time moving but not us, with the wonder of cell phones and smart phones and internet connections, but United Airlines cocooned off and unreachable. Couldn’t get SFO itself either. Not that it would have mattered.

I just heard from them, 14 hours after we left this morning. Lola was good, but slept only 15 minutes and spilled four different liquids the ladies were trying to drink. I had said, why not wait for tomorrow? But Ann said, no, I’m going today, if we have to go on any airline, if we have to go through Honolulu; we’re going. The lure of Maui is just too great. Maui is warm, the pool is warm, the surf and beach are beautiful, and the Sports Page beckons. Maui is something special for Ann, beyond the obvious. There is something that draws her, something that makes her relax, feel good, flow through the day. Probably because she was there all the time as a girl when her father consulted for Chevron and there was nothing at all where our house now stands. We are sometimes asked what we do there. We say, mostly wait for repair men. But it doesn't matter, there's something in the water.

So, I’m wondering – we left home in plenty of time under normal circumstances. I’ve been a very good boy. I have taken her habits and made them my own. We’re not going to leave any earlier next time, are we? I guess not. Being early is sensible, if you think about it. We're not nuts, just prudent. Took a long time for me to get there.

Budd Shenkin

Sunday, October 17, 2010

Maui Stories

Maui is a small island with a population around 160,000, I think. A small county in a small state. Lots of the permanent residents know each other, or of each other.

We have our celebrities. I hear Oprah has a place or two, but I haven’t seen her and I don’t know if she really comes. I know that Arnold and Maria were looking for a place and looked in Makena, but I don’t know what they finally did because someone else bought that beachfront house for about $29 million, I heard. Cute little place.

So, I’m flying over from Oakland last month and who is sitting behind me but Don Nelson, long time coach of the Warriors. He is an island notable and has a place in Kihei, Hale Nelson. We walked off the plane together and struck up a conversation. I was mindful that he had been fired the day before and might be sensitive, but on the other hand he collected $6 million buyout, I think, so not all has been lost.

So after a few remarks back and forth, including my telling him that I had seen the first NBA game where Russell faced Chamberlain, I said,”Don – I saw you play!” He said, “I thought everyone who saw me play was dead.”

He is 70, not much older than I am, and vigorous, which I am, too. But obviously mindful of that horrendous number. Actually, except for the loss of my parents and one particularly upsetting and dysfunctional relationship with a loved child, I am as happy as I have ever been. Secure and still excited by my work. It’s like autumn back in Philadelphia. I used to think, this is really the best time of the year, fresh aur and beautiful foliage and football, except that we know that winter is coming.

Anyway, Don (he became “Don” to me) said that he was renting Hale Nelson out now and had moved up to Paia, where it’s cooler and rains more. I know he is a member of an island-fabled poker game with Willie Nelson and I think with Kris Kristofferson. Also with local notable Steve Goodfellow, I heard. And then he said that he was busy investing his whole “fortune” -- a word he emphasized in a way that made me think that here’s someone who came from a non-fortune background, and thus doesn’t take it for granted, but still looks at it with a little amazement that he did it -- his whole fortune on Maui. He is constructing some kind of place in Kihei for weddings. And up in Paia he has a coffee shop, where he invited to come up and visit. Would have done it, but I was only going to be on island for 6 days.

So I thought, he might be done with basketball – it looks that way – but he’s not through with action. Basketball had become a business for him, a special business but a business, and he isn’t about to give this attitude to life he has adopted for decades.

OK, that’s my Don Nelson story. Now here’s my Gordon story. Gordon is an Aussie by birth and speech, but an American by residence and business and American son since the age of 20, which was a few decades ago. Gordon lives in our condo complex and is as people-oriented as God makes us. Gordon knows everyone. We have a mutual friend, Anne, who lives in the complex also with her husband. So, Anne got a mattress for their bed. She tried and tried, but after six months she just couldn’t get herself to like it. So she decided to sell it and put an ad on Craig’s List. She got a call for the used mattress from a guy who lives up country, and he naturally wanted to come down and try it out. OK, Anne said, let me tell you where we are and how to get here. She told him the condo’s name and he said, “Hey, isn’t that where Gordon lives?”

“Why, yes it is.”

“Well, I know how to get there. In fact, I know the entrance code!”

This is a true story. As I say, it’s a small island, and Gordon knows everyone. But I have to say it reminded me of the famous story that ends with the narrator standing with the throng outside St. Peter’s and asking a bystander if she knows who is up there. The bystander says, “Of course I do. But who’s the guy in white standing next to Hymie?”

Pretty funny. I had to laugh.

Budd Shenkin

Saturday, October 9, 2010

The Culture of Enabling

Dear readers, please permit me a dyspeptic screed.

There is a conspiracy of silence in this country. No one assigns responsibility. We enable failure. It starts early, when everyone on the kids’ team that went 0-14 for the season gets a trophy. And that’s just the start.

Pop psychology has no doubt played a part. “Positive reinforcement” is what we operate on. Look only at the positives.

Our Berkeley mothers say in dulcet tones, “Now, Joshua, Mommy needs you to take the knife away from your little sisters throat, right now.”

“I’m going to kill the little bitch!” says Joshua.

“Joshua, don’t you think you would be sad if Kelsey wasn’t here, and wouldn’t Mommy be sad?”

Well, maybe that’s an exaggeration. Somewhat. Maybe it's off the point - OK it probably is. It was just on my mind.

But seriously, what about responsibility? For instance, anybody know who screwed up the O-ring? We know that the Challenger went down because of a faulty O-ring design, that a defective NASA culture enabled it, that Morton Thiokol was the designer, and that NASA ignored warnings of engineers that low temperature was especially dangerous for the O-ring. But I want to know some names. Who did it? Who was on the team of designers? Who in NASA ignored the warnings? Why the anonymity?

We know the heroes well enough. Sully heroically saved a plane after a collision with birds, and showed up at every significant event afterwards for a year, and I felt as good about him as anyone. We know it was Francis Kelsey at the FDA who blocked approval of Thalidomide – in fact, go to Wikipedia and you will find a photo of her with President Kennedy. Success has a name.

But where are the anti-heroes? America needs them!

Who the hell was it that confused inches with centimeters in 1999 when NASA lost the $125 million Mars Climate Orbiter spacecraft after a 286-day journey to Mars, when thrusters used to help point the spacecraft had, over the course of months, been fired incorrectly because data used to control the wheels were calculated in incorrect units? The company was Lockheed Martin, which was performing the calculations, but who was the stupid engineer who did it? Why can’t we know?

Who screwed up the Hubble? Remember that? A small defect in one of the two mirrors was caused by a 1mm error in one of the machines that made it. This error made the telescope worthless, and only scientific heroics in 1993, at great cost, saved this treasure. The company at fault was Perkin Elmer in Connecticut. OK, we have a state and we have a company. But who, I want to know, made the error? It was somebody. Anyone got names? I don’t. What’s the theory, that they have suffered enough? Not in my book. I doubt that this achievement appears on his CV.

And who was the idiot that drove his truck off Interstate 880 and tied up the East Bay for months when he drove his oil-laden truck too fast in the middle of the night, crashed, and burned the freeway up? If we can’t have his name, can we at least have his ethnicity? Give us something!

In sports a lot is out in the open. Poor Bill Buckner – a long and distinguished career, but we remember the ball trickling through his legs at first base. We know that name. His error is a measuring stick for all other errors. It's painful, but it serves a function, and has a name. But even in sports the don’t-put-a-name-to-failure affliction has begun to infect commentators. In a Giants game a week or so ago, bottom of the ninth and two runs behind, I think it was Freddy Sanchez who was thrown out trying to get to third when he could just as easily stayed on second, since his run was meaningless – they needed two. It was only a rather amateurish new hire commentator who pointed out the mental error. Someone had forgotten to issue him the requisite rose colored glasses, or rather microphone. The regulars didn’t criticize anyone. Freddy’s a good guy, but this willful look the other way attitude debases the sport and our intelligence.

And just yesterday in the SF Chronicle we read that the California Air Resources Board overestimated diesel pollution by 340%. It was due to “a faulty method of calculation.” This comes on top of a miscalculation last year that overestimated the number of diesel-related deaths. Needless to say, we are given no idea at all who is responsible. “I think somehow some very poor decisions have been made,” says a Board member. Jesus. “Who” is a person, not an organization, a system, a process, or a culture.

Does it matter? It actually probably does. The culture of positive reinforcement has all but extinguished taking responsibility. And what about the entertainment value? Just as medicine has named syndromes after someone who described them first, we are missing the opportunity to name specific types of errors after their most prominent perpetrators. Wouldn’t such terms as “The McCarry Miscalculation” elevate our cultural heritage?

So, let’s stop the cover up! Here is a modest proposal to get the ball rolling: the esteemed non-profit organization, the Center for Responsive Health Policy, should offer a trophy to any individual reporter who succeeds in placing a specific name with a specific error in a major publication or blog. The name of the prize will be the Yudunit Award, or a Yuddy. You can imagine the image of the trophy – an enormous pointing index finger. You want trophies? You got’em. I know just where to get them, from Mary and Joe’s Sports Store down on San Pablo. They sell them by the dozens.

Other proposals are invited.

Budd Shenkin

Tuesday, September 28, 2010

Top 10 List of Physician complaints about insurance companies

I know we have covered much of this same ground before, but I thought it might be worth posting this listing of complaints that we developed on the SOAPM listserve.

Health Insurance Companies vs. Doctors
The Top Ten Outrages

From an idea of Jon Caine, MD
With the aid of unindicted co-conspirators from the SOAPM Listserve
Written by Budd N. Shenkin, MD, MAPA

The outrages perpetrated by health insurance companies against their policy-holders – people we physicians call, perhaps anachronistically, “patients” – were aired and to some extent repaired in the run-up to and passage of the Affordable Care Act (ACA) this past year. What went largely unremarked and unaddressed, however, are the outrages perpetrated by health insurance companies vis-à-vis the physicians they contract with to serve these selfsame patients. Here, for your wonder, perhaps your outrage, or if you are a health insurance company executive, your amusement, is a top-ten list of these outrages.

1. Unequal anti-trust policy. The biggest outrage, the ur-outrage from which all other outrages spring, is condoned and supported by the laws and enforcement of the government of the United States and the various states. Health insurance companies operate in largely monopolistic and oligopolistic environments in local areas. Physicians practice in much more atomized small group practices. The playing field is severely tilted – insurance companies can do without an individual physician practice, yet the physicians cannot do without the insurance companies. Governments have allowed anti-trust laws to accommodate insurance company consolidation, but have enforced the law on physicians, and will not allow them to negotiate as groups, even when members of IPA’s and other groups. The predictable result is that insurance companies continue to lower payment rates to physicians to the point of near extinction, and to commit outrages to decency such as those listed below. In reaction, physicians are now themselves conglomerating into corporate entities, not because this is a better way for them to serve their patients, but simply to protect themselves from the oligopolistic insurance industry. Coming soon to your community – Large Corporate Physician, your doc in the corporate box. The ACA could have given a anti-trust waiver to allow doctors in organizations such as IPA’s to bargain collectively with oligopolitic insurance companies.

2. Payment for vaccines. Vaccines are the greatest life-saving advances contributing to the health of the public since safe drinking water. Medical practices, amazingly, have overhead – a typical primary care group practice has an overhead rate of 65-70%. But many of our friendly health insurance companies have declared it their policy that “physicians should not make a profit on vaccines.” Therefore, when a physician administers a vaccine, a company with this policy will pay the physician only a few percentage points above the acquisition cost of the vaccine. How long would Macy’s survive if it sold a shirt for 5% above purchase price? The ACA could have required insurance companies to pay for vaccine cost plus overhead plus margin.

3. Adherence to the Payment Code Policy. There is a codebook called the CPT codebook. Whenever a physician does something, there is an official code on how to describe the service, with a Relative Value assigned to this code. Physicians are required to adhere to this codebook; no deviations are allowed. Insurance companies, however, often deviate. There are codes, for instance, for administering a vision test, a hearing test, a urinalysis, etc., to a child. These are separate services recognized by the code book. But many companies “bundle” these separate services and simply declare that “these services are included in the payment for the visit.” Which they clearly aren’t, which is why they are listed separately and have their own codes. The ACA could have said, “Insurance companies need to recognize all CPT codes and pay according to their relative value.”

4. Up To Date Codes.
In a related vein, when new services such as new vaccines appear and are approved, health insurance companies lag for months in inputting the codes “into the system.” This leaves the physician in the lurch, wanting to give the service to the patient, but not being able to get paid for it by the health insurance company. Amazingly enough, when time comes that they decide to delete a code, the health insurance companies can accomplish this immediately. The ACA could have fixed this by requiring the code addition to be timely.

5. Double dealing in eligibility. When a patient comes to the office, physicians need to know if the patient’s insurance is in force. The insurance companies, keepers of the data, have websites that the physicians can check. But this information is sometimes out of date. If a website says a patient has insurance in force and the physician accordingly serves the patient and sends the bill to the insurance company, but the information turns out to have been false, the health insurance company commonly reneges on its responsibility, and doesn’t pay the physician. The ACA could have compelled the heatlh insurance companies to honor their own information, and to pay the physician for service rendered in good faith.

6. Payment for services on capricious criteria.
A prime principle of prevention is early detection of illness. An important way to do this is to screen all patients. For instance, pediatricians use scientifically-validated screening procedures to detect developmental delay, autism, hearing loss, or high cholesterol. But some health insurance companies pay for these screens only if the patient actually has the disorder in question! Talk about unclear on the concept. The ACA could have compelled the health insurance companies to pay for the screens when applied at the officially indicated age intervals.

7. Takebacks. Since the health insurance companies are constantly sending doctors payments, if they want to they can simply debit a current payment for a past problem they detect, with no form of mutual adjudication. From a fellow physician: “Last week I had a takeback from BCBS for a patient visit one year ago. The problem was not that the patient was no longer eligible, but they had never responded to the BCBS inquiry about other insurance coverage.“ That’s right, the insurance company sent an inquiry to the patient asking if they had additional health insurance coverage, the patient didn’t respond, so the insurance company retroactively voided their payment to the physician. The ACA could have mandated no takebacks without mutual adjudication.

8. The Lapsed Coverage Waltz. A colleague reports: “Patient's coverage lapses in error. They call the plan to get reinstated. The plan reinstates the patient from the date they called, not back to the erroneous termination date. Doctor still does not get paid.” The ACA could have fixed this, too.

9. The Myth of Timely Payments. From another colleague: “State law mandates payment of "clean claims" within, say, 30 days. On day 28 they send an inquiry to the patient (with a copy to the doctor), requesting ‘information on any other health care coverage’ and the claim is pended until that information is received. Since it takes the patient some finite time to respond, if they bother to at all, the doctor is left waiting for payment.” Surely the ACA could have obviated this tactic as well.

10. Show Us Your Documentation.
One of the most wasteful practices of the health insurance companies is excessive documentation demanded from the physician. Before paying for a service, the health insurance company can require the physician to send copies of the patient record. The number of such requests can amount to harassment. Some health insurance companies will require documentation for every single instance of a service, such as a screening for autism. In our own practice, with some companies and some codes we have now resorted to the extra work and expense of submitting such records expectantly. What a waste of effort. The ACA could have regulated the number of such requests.

11. Rudeness and Mendacity. As a bonus, for #11, let us mention my own personal favorite. Industries tend to attract certain personality types, and to take more malleable personalities and mold them to a common image. The capacity of health insurance company executives to misstate facts and demean inquisitors is legendary. Virtually all my colleagues who manage practices have been told that they are the only one in the state, region, or country to protest or be dissatisfied. I myself have been told that the American Academy of Pediatrics supports the position of the health insurance company on an issue, when I myself have been part of the committee that sets the policy. Whoever invented the word “chutzpah” couldn’t have had a strong enough imagination to envision its embodiment by the health insurance industry.

Colleagues have requested that our list go on, but in deference to David Letterman, we will stop at ten plus the bonus. We all know that the American health insurance system, even after ACA, needs revision. In the grand scheme of things, this list of grievances might seem small potatoes, but to those of us in the system day after day, it is major. Since the Federal Government has shot its bolt with the ACA, which failed to address these issues, we most likely cannot expect any relief from this or any prospective Congress or Administration. Our best hope, then, would be the states. As practitioners, we can fight the good fight on our own, but realistically, only government has the capacity to curb such bad behavior.

Budd Shenkin

Saturday, September 18, 2010

Adventures in Primary Pediatrics

Leave it to medical couples to have interesting children.

I have a lovely, low-key family in my practice with a three year old in for a check up. He is a quiet child, non-obstreperous, maybe even diffident, much like his charming and engaging very low-key nephrologist Dad. He has had a little trouble with constipation and is not enthusiastic about the potty, which he seems to fear. But his development is great – very verbal, draws a cross on the exam table paper with no hesitation. He thinks I’m funny (true, I am). A nice, smart little boy.

So as I was examining him with his parents seated over by the window, and his Mom, Laurie, said, “He says he doesn’t want to grow up.” Now, I haven’t heard this symptom very much, and from a three year old! But child psychology is something I enjoy. It gives me room for imagination and creativity, and it’s something many pediatricians are a little deficient in. So, a chance to engage! And with a boy who thinks I’m funny, especially when I do my Donald Duck talking.

So I said to little Grayson, “Well, that’s OK. I didn’t want to grow up, either.” A little tittering from the parents in the Peanut Gallery, but actually it’s true, I didn’t. Why grow up? It’s great being a well-loved little boy, and in my case, the #1 son, as my father used to say, recalling the Charlie Chan movies of his youth. I’ve always regarded development as a double-edged sword, and maybe little Grayson does, too.

Did Grayson feel too much pressure to “grow up” from these accomplished parents? Were they more striving and directive than I thought they were? Was being #2 son too much for him, and he was retreating from the competition? What would they be demanding of a three year old boy, after all?

So, follow the logic. What would the developmental challenge be to a three year old, this three year old? Toilet training, of course. But why would he not want to toilet train? They said he was afraid of the potty. Why would he be afraid? Projective fears (see Bettelheim)? I asked him – are you afraid that the potty will eat you up? He looked mystified at that. Well, it was a try, I thought.

But then why would he fear the potty? Which potty did they use, one on the ground (preferred) or one on the adult toilet? The sound of that toilet gurgling can be intimidating. They use the ground-based potty, and he didn’t seem to have any reaction as I talked to him about it.

Then the “Aha!” moment. He’s constipated! What does constipation mean? Pain, torture. (With Portnoy’s father, I believe that colonic health is the doorway to happiness.) So what does he hear about growing up? Big boys use the potty. I don’t want to use the potty, he thinks, it hurts! So, the intelligent solution for this verbal and intelligent three year old doctor to be, specialty yet unchosen? “I don’t want to be a big boy. I don’t want to grow up.”

A chuckle of appreciation from John in the Peanur Gallery. “Of course,” said in appreciation. I felt so good, the triumph of discovery. Of course, it should have been obvious from the start, it’s pretty basic pediatrics, and as I enjoy and congratulate myself, it’s really quite elementary. Still, I’ll let myself enjoy it.

I had a long, hard time finding pediatrics as my vocation. And I still feel humbled by the task. But you have to admit, this was pretty cool.

Now to fix that constipation.

Sunday, August 29, 2010

Primary Care - My KALW Interview

It wasn’t the prospect of a hanging that did it in my case. For me, my mind was concentrated by my being interviewed for KALW by a very intelligent journalist on the subject of primary care. I’ve always said, if you can’t explain something so that an intelligent layman can understand it, you probably don’t understand it enough yourself. I don’t know how it will be for the listeners, but for me it was a very good educational experience. It clarified my thinking.

Being me, I found the interview an opportunity to disagree with all three of the other interviewees for this project, all of whom I know and like: Tom Bodenheimer, MD, of UCSF internal medicine; Kevin Grumbach, MD, of UCSF family practice, and Richard Scheffler, PhD, of UCB School of Public Health. Interestingly, I found myself to the traditional Right of the two academic docs, and skeptical of Richard’s traditional economics view of medical care, although let me say, not dismissive of any of them. They are all smart and thoughtful and worthy on all levels.

Tom has published great articles on the plight of primary care, and accurately focused on money as the biggest problem. Some people say primary care is too difficult to do, not professionally rewarding enough as compared to specialities, etc. Tom doesn’t buy this and neither do I, and neither does Kevin for that matter. For a person-oriented physician, noth other specialty provides the long term relationships of primary care. But faced with the prospect of primary care for $120-$190K a year, vs. anesthesiology for $600K a year – is this a choice? Not to mention cardiology, ENT, ortho, various surgical specialties, etc. You don’t have to be an economist to figure this one out. But my interviewer said, do primary care doctors need more money, or as Tom Bodenheimer says, are the primaries getting enough, it’s the specialists that need to get less, so the choice of a medical student is less economically based?

Time to disagree with Tom. I’m reminded of one of Martin Amis’s books on Russia, when the young people are parading around saying, No One Should Be Rich! An old lady says, I remember when we said, No One Should Be Poor!

Tom (and Kevin) represents a strand of medicine that I call the missionary strand. We do have a priestly role, but I personally have no desire to wear a hair shirt, and neither do most doctors. I don’t ask for poverty, I ask for an even playing field. It’s true that doctors in the US make more than in other countries, but that’s not true of primary care docs. If all doctors were to make less money, medicine would be less attractive to the elite, and I’m for as many smart and aggressive and entrepreneurial and progressive and inventive minds as possible in medicine. Economics works.

My interviewer said, but given more money, would the doctors just bank it? I said, to some extent, but then what we see now is primary care doctors with insufficient resources to bulk up the office with nurses and other personnel – we train the staff, then they leave for hospitals and specialists offices, where the money is. We are asked to be a medical home, calling patients on the phone to see how they are doing, and directing patients and spending more and more resources for patients, but to do this we need more money to spend. It has to stop all going to hospitals and specialists – but I guess I’ve mentioned that.

Would primaries do that, spend some money on the practice as well as bank some of it? They would if there were a fair market. Patients appreciate these aspects of care, they aren’t hidden as are some aspects of quality. So patients would choose to visit the doctors who had beefed up their offices with the enhanced payments they receive. In this case, the market would work.

Kevin says that hankering for the past security of your friendly neighborhood doctor is passé. He says that much of primary care can be accomplished by midlevels (nurse practitioners and physicians’ assistants), nurses, and others, so we should husband our physician resources and save money and be more efficient by having independent nurse clinics and much more clinical work done by others than doctors. I disagree.

First of all, the problem of medical cost does not stem from primary care, it stems from the money pit of hospitals and specialist services, and IMHO it is more a price problem than a volume problem. So you’re going to fix a money problem occurring elsewhere by economizing in primary care? I think this is a very poor solution. Since I tend to be sometimes belligerent, I say – Don’t give in to those schmucks!

At Bayside we have NP’s and PA’s and we love and respect them, definitely. My own step-daughter often chooses to go to a PA for her own care. But our PA’s often go over to our lead FP MD and ask him questions, seek assistance and direction, etc. They are not doctors, and they don’t think they are.

What is it that makes me value a doctor so much? Is it because I am one? I don’t think so. Mid-levels do well on measurable quality parameters, but quality assessment is still rather rudimentary. The deeper considerations a doctor makes, the questing after difficult diagnoses, the balancing of judgment calls – doctors weren’t highly selected and highly trained for nothing.

Kevin is right that we need to beef up our offices with personnel other than physicians – the medical home is a good and important concept. But he needs to be a little less enthusiastic in calling for a substituting for primary care doctors and economizing. In our country we should be able to afford primary care doctors, and we should be able to afford a first-class primary care system.

Kevin also seems to represent a potent line of thought that the Obama Administration has mindlessly adopted – that we need to have larger systems of care – Kaisers and other large entities – and primary care needs to get out of the communities and into the large organizations. I couldn’t disagree more. The local doctor’s office is personal, and the best doctors in these offices care for their patients, and moreover, care about their patients in a way that an employee of a large organization just won’t. Sorry, they won’t. And anything that a primary can do in a large organization with quality enhancement, we can do in our local offices. I personally think the offices need to be larger than just one office, but the best offices can do it even with three or four docs. They just can.

An example of caring: my friend Bob Shimizu is a long time pediatrician at Lamorinda Pediatrics in Lafayette. He recently cut back his hours markedly and feels much more relaxed. I asked him what the big difference was. He said, “The worrying. I would get so worried about some of my patients. That was really getting me down.” Worrying outside the office. Caring about his patients, not just caring for his patients. Think that’s happening at Kaiser? Betcha not.

Richard had not yet been interviewed so whom I couldn’t comment on what he had said. But I had read his interesting book, Is There a Doctor in the House, and my interviewer was sharp enough to anticipate some of what he would say –do you agree with Scheffler that it is all right to have to wait to see a doctor?

My answer is no. In this respect, medicine is not like other goods and services. It is OK to wait for cable installation, but it is not OK to wait to be evaluated for sudden feelings of weakness and arm pain that could be musculo-skeletal, or could be heart. Urgent care and ER care are not substitutes for good primary care by your own doctor whom you know, and who care about you and you know cares about you, and who is good and competent, and you know is good and competent. There is no substitute, and waiting is not OK. As I said, I like and respect Richard, but his strength is also his weakness, which is that he is an economist. Waiting might be fine in economics because it is cost sparing, but add into early detection the issue of patient anxiety, and you have to be better staffed than what is envisioned by economics. Plus, it’s all because of the horrendous rents paid to monopolistic systems of care at the hospital and specialist levels that we even contemplate savings in primary care, which is so inexpensive by comparison.

I loved being under the pressure of this interview, but typical of me, I found a way to disagree with everyone else on the panel. But hey – I still think I’m right. Don’t you?

Budd Shenkin

Thursday, August 26, 2010

Carpe Diem

In pediatrics there is a syndrome called the “vulnerable child.” This occurs when a child has a severe illness, such as prematurity, a severe accident, a severe event. Parents are scared out of their wits, and when the child recovers they wonder,, is he OK? Was damage done that isn’t apparent? Supernaturally, is there some fatality at work that will emerge later, a tainted future?

When I was just starting in practice I covered for a colleague on his day off. I saw a teenage boy, big and strapping, six feet tall and muscled, probably played on his football team. I examined him and told his worried mother, “He looks OK. Nothing serious.”

She said, “Are you sure?” Pause. “Doctor, he was a premie, you know.”

Luckily, I knew about Vulnerable Child Syndrome. I had to laugh, and told her that her fears were understandable, because she had been through a trauma that left her considering her football player as somehow vulnerable. I said, “But look at him! Don’t worry.”

In our house we have our own vulnerable child. Peter had his birthday yesterday. The little tyke is now 27 and a third year law student. He was a premie himself, 35 weeks, five pounds seven ounces, while his mother had HELPP Syndrome, which was then a month or two short of being described in the literature, which left us to fend for ourselves in diagnosis. She presented with a nose-bleed that wouldn’t stop because her blood was coagulating within her veins. Luckily she went into labor and had Peter – in those days a trained nurse or technician didn’t attend every delivery, and it was left to me as the father to resuscitate Peter, which I did, but he was in the hospital for over a week, I guess, looked like a drowned rat, and Ann had a bone marrow aspiration and clotting tests for days in the ICU as she recovered, which she did, since pregnancy is the cause of HELPP.

Then at age two Pete needed heart surgery to close a hole, called an ASD. But not before the insurance company tried to revoke our policy, on the grounds that we failed to reveal when we got the policy that Pete might need surgery, which of course we didn’t know. This insurance company practice, called rescission, was just outlawed by ACA (Obamacare). That operation went well. He was up and in the halls saying “Pitch to me!” just a few days later, amazingly, on the same floor that I had done my residency on.

Then at the beginning of his junior year of high school Pete was on a camping trip to foster class solidarity. In the middle of the night a 4,500 pound tree fell in the midst of the sleeping group and Pete was only saved because, to the amusement and derision of his classmates, he had brought a very puffy air mattress along with him – he apparently shares his mother’s and father’s attitude to roughing it. The tree fell right on him, but the air mattress cushioned the blow enough that he escaped with losing a kidney, 18 inches of small bowel, five broken transverse processes of his lumbar spine, a broken wrist, and no trauma to the spinal cord. It was weeks and months of recovery, and the scars of the heart surgery and the tree trauma now form an anterior zipper line from neck to pelvis, almost. You can imagine the trauma his parents endured as well, with the 4:30 AM phone call of your son is in critical condition, and the days afterward.

Pete now has a truly existential view of life. He knows that we all die, and that we could do so at any moment. He is not afraid, but carpe diem is definitely for Peter.

And so it was that we received word yesterday of how Peter celebrated his birthday. Peter went sky diving from 18,000 feet and loved it.

He told his parents afterward. That was thoughtful of him.

Budd Shenkin

Tuesday, August 24, 2010

The Week of an Administrative Physician

Last week I went to our Dublin administrative office to console our staff about the sudden death over the weekend of our 32 year old beloved co-worker Preneet; conducted three clinician office meetings on Monday, Tuesday, and Wednesday; saw patients; delivered a eulogy at Praneet's funeral before 400 attendees; interviewed a candidate for Administrator; visited the Berkeley office and consulted with our lead FP there about our office direction and his staffing problems; conducted our weekly business office meeting, while signing checks and reviewing our final contract offer to our Administrator candidate, and contacting the CEO of Children’s Hospital about poor care in the ER and trying to schedule a meeting with him; attended the Children First IPA Board meeting; consulted withe the CEO of San Ramon Regional Medical Center about a new office for us and recent movements of other doctors in the area; gave a day long deposition on a totally bogus wrongful termination and assault and battery lawsuit brought by a wretched former employee; consulted with experts, lawyers, another clinician, our HR Manager and an office manager about what to do with a physician who was possibly impaired; contacted our probably not impaired clinician and worked our way through our course of action; had a radio interview on the subject of primary care; and prepared for a meeting the following week with a physician who was not meeting expectations in various behaviors and documentation. Among other things.

Then over the weekend I asked our scheduler for rounds and call, the beloved Tina Hong, MD, my co-author on a recent Pediatric Puzzler in Contemporary Pediatrics, to do a little rescheduling of rounds and call to account for the temporary absence of our also beloved possibly probably not impaired physician, which she expertly and happily did. So Tina said, “Where have you been, on a cruise? I haven’t seen you!”

Such is the work of administration.

I had to laugh.

Sunday, August 15, 2010

What's It Gonna Take?

I was on vacation the last two weeks of July, cruising. When we cruise, we read. My first book was City of Thieves by David Benioff. During the 900 day Siege of Leningrad two young men have adventures, including an encounter with cannibalism (true), in searching for a dozen eggs. Good book, excellent even. Recommended.

But the big book I read was Winston’s War by Max Hastings, obviously about WW II and Churchill, from his accession to Prime Minister to his electoral defeat during the Potsdam conference. Hastings says, btw, that the defeat was warranted – not rejecting his wartime leadership, far from it, but with the war just about over the focus would be on domestic policy, and Churchill had scant interest in domestic issues, and what interest he had was retrogressive. This is not hagiography, but lots of warts as seen by others, and with full range of the doubts of people of the time, large and small people and doubts.

What struck me very forcefully, although I knew it before, was how Americans and the British for years denied the existence of the Nazi threat, or minimized it, or in the case of the British upper class, sympathized with it. It took so long for people to come to terms with it! In retrospect it is so obvious. It’s not in this book, but if the Allies had only stopped the Germans from occupying and remilitarizing the Rhineland in 1934, the Nazis would have backed down and history would have been different. That’s fact, not surmise. From then on it was a progressive steamroller, Chamberlain’s famous dance of appeasement, and war without Western preparation.

Then the Americans – even with much of Eastern Europe, the Netherlands, Belgium and France occupied, even with Britain under siege, most people in the US thought they could and should keep out of it. Just amazing.

Yes, there were mitigating circumstances. Britain and France had lost a generation in WWI and were loathe to re-engage. Americans did not like nor admire the British. “Toffs,” they were regarded as. Poor fighters (with reason.) Enslavers of the Colonies. Plenty of reason not to like them. Plenty of reason not to admire the French military as well.

Who saw the necessity of opposing Hitler? In Britain, Churchill first and foremost. In the US, Roosevelt for sure. But leaders are not dictators and it took time for the countries to catch up, to see more and more clearly what they were up against. No one wanted to change what they were doing, no one wanted to think of war again. So they denied it.

Denial is an essential part of life. We generally don’t think much about our own mortality, a kind of denial. If you look at yourself and think about it, right now, I bet you can think of things you are denying right now. Just not thinking about it, and going on as if it didn’t exist. It allows you to be functional. But sometimes it’s not a good idea.

In the case of WW II, it took Pearl Harbor for America to stop denying. That did the job pretty well. We still don’t know what would have happened with Europe if Hitler hadn’t declared war on us later that week. But he did and denial was over.

I do recommend this fine book. As a journalist, Hastings is able to take us back in time so vividly, to abolish knowledge of the ending just for a little, and see what the atmosphere really was at the time. He shows us that retrospective clarity is an illusion.

How does this apply to the present? We all know Santayana’s comment that those who don’t know history are doomed to repeat it. That’s essentially a hopeful statement, implying an ability to form the future through reasoned action. But it’s also possible that those who do know history are just as doomed to repeat it as those who don’t. In John Steinbeck’s redo of the Arthurian legend (another book recommendation from Budd) Merlin is asked: “If you can know the future, why didn’t you look ahead and see that this woman would be the death of you?” Merlin replies, “Oh, yes, I can foresee it, but that doesn’t mean I can avoid it.” Makes sense to me.

So here’s the question: Given the power of denial, what’s the biggest issue we are not facing now? What is the equivalent of the brewing Nazi and Japanese crisis of the 1930’s?

Islamic terror? Nah. We are spending huge time and money on it, but it’s really just an annoyance – what can they really do, how many of them are there really? It’s mostly drama. Even if they got a WMD. Even if Iran went nuclear.

Islamic expansionism? Maybe – look at France and especially the Netherlands. Look at how Islam took Kosovo from the Serbs by sheer procreation of the Albanian-Islamic minority become majority. But while a problem, it will be handled more or less, and I don’t think that’s it.

Rising countries with non-democratic governments? Maybe. We used to like to think that liberal democracy was ascendant since the demise of Communism in the USSR and Eastern Europe. Certainly something to contend with – Fukayama’s “End of History” was ridiculous when it was published and is now risible. I love liberal democracy and the Bill of Rights, but that’s a product of our specific Western culture, and its ascendancy was based on our economic and organizational power, which will soon be matched. So, it’s a problem, and it’s true that most people are not conscious of it. But I don’t see it as an impending crisis, just a persistent challenge. Competitive coexistence is most likely.

No, my candidate for major pending crisis in denial, crisis in the same league as Nazi Germany and WW II, is the environment. It’s not an unknown issue, but neither was Nazism. It seems quite clear that overpopulation and industrialization are burning up our planet. Ever since we discovered all that fuel below the surface of the Earth we have been burning it up, and in the process burning ourselves up. We use some of it well, but the “externalities” (to use economist-speak for pollution and carbon dioxide accumulation) come back to bite us, as the lobster-pot we live in heats up, more and more obviously. It’s an impending crisis, but it just won’t explode in the next year or two, so it’s possible to deny it, especially if you are over 50, where the power lies.

I see the Nazi parallel. Hitler built the military month by month, people saw it, but most preferred to think one could reason with Herr Hitler, or thought he was pretty far away in space and/or time. Our decade of the aughts has gotten hotter and hotter, but what the hey! Maybe it’ll stop! Maybe it will be a good thing? Who cares what happens to Bangladesh and the Maldives? Not our problem, is it? Do we really want to change our habits and economy substantially? Or do we say, like St. Augustine, make me chaste, but not quite yet?

As in the 1930’s, the forces of inertia are still in control. Greed is in place – oil and coal interests pay “scientists” to deny global warming. They pay Congress not to tax carbon. Developing countries are also resistant. They say, why should the West have the good standard of living and not us? Politically, it’s a game of chicken. China and Brazil say, we’re going to make progress – why should you always be ahead of us? We say, hey, we’re already here, don’t you realize you will make it worse for all of us? Why are you burning coal? You are making it worse for all of us. It’s a game of chicken.

A gradual approach now, like rearming would have been in the 30’s, would be to hitch profits to moderating climate change, by government incentives. But governments are weak. Corporations and sovereign funds rule the world, and they make money by doing the same thing they have been doing, time after time. There is even an ideology that these entities should not be looking for the common good, that “the market” will take care of it, and technology will “appear.” These are arguments of convenience. We are dealing with economic externalities, and as I understand it, such effects by their very definition do not enter the market. So the ideological market argument is specious. We need strong governmental intervention, and not only are our governments weak, but populations are in denial.

No one really wants to change. Psychologically, it’s just denial. Morally, it’s selfishness of the current generation. Intellectually, it’s often just stupidity and ignorance of science. And as we look for leadership, George Packer tells us, don’t expect much from the Senate. Our institutions fail us just as much as the British ruling class and our own isolationists in the 30’s.

To be educated, to see the future to some extent, to know some steps we should be taking now, to see little happening, is to feel like Merlin.

So, I ask --What’s it gonna take? What will our Pearl Harbor be, or our invasion of Poland? Nobody knows. I don’t know. But if this really is the brewing crisis that is being denied, then it might take something dramatic.

The environment is not my field, so I can’t speculate intelligently about what it will take. Hunger and thirst, rising sea levels and tides? Maybe. Maybe even as the Earth gets more and more depleted of forests, would it be possible that the oxygen level in the air, at 21% for millions of years, would drop, and we would all be living as though we were high in the Andes and Himalayas?

This is as far as I can get. History allows us to reason by analogy, but it is never exact. I know we are denying something that is important, and if we prevented it, that would be better than fighting it later. And I think it’s the environment. And I think it will take something dramatic to move us. And I think there will be a lot of conflict, that it won’t be peaches and cream. I wonder what it will be.

Budd Shenkin

Saturday, August 14, 2010

ICU's, interesting cases, and Primary Care

Atul Gawande is a genius writer in my book, or rather in his books and articles. But, even though I think his mother was a pediatrician (in Ohio), he is still a Boston-based high powered endocrinologic surgical specialist. So, in his latest New Yorker article on the depredations of high powered specialities ICU care and end of life expense and torture, I think he steps on his lede.

In the article Gawande writes very approvingly about hospice care, and recounts the torture inadvertently administered by the ICU doctors to dying patients. At the very end of the article - every article he writes is more than worthwhile reading - he mentions a case where the primary care doc had kept in touch with the patient and with the prospect of ICU care the primary doc gets the patient turned off, then quietly exits stage left.

Hey, Atul! That's the whole ffing point!! It's primary care, man! It was also the point in your South Texas article of the best little medical money machine in Texas. Stop stepping on your lede.

He and the other New Yorker doctor-writer, Jerry Groopman, also generally quite well worth reading, especially on EMR's in the NEJM, come from the background of intellectual (I'm not using that word in a good sense here) pompous (also not in a good sense) Boston specialist doctors (also not in a good sense) on rounds saying, "Hmmm. A very interesting case indeed!" And then they trot off the the next. Some decades later, Groopman says, in the face of caring for his own medical needs - hey! There are people in there with these "interesting" diseases!

No s... Dick Tracy! There are others of us, who I can only think very often wound up in primary care, who from the very first said, "What are these guys doing?" Don't they realize they are dealing with people? Is this part of the God complex? So removed? Then they come back to see, post-seduction, what the game is really about.

For a great comment from a pediatrician turned health policy guy, and classmate and friend of my step-daughter Sara, see

While I'm on this rant, might as well take on the academic liberal primary care establishment who take the position that those who look nostalgically to the family doctor of the 50's are doomed to disappointment. They say, we can't do that in this day and age. We need to cut costs and be efficient! We need to have Nurse Practitioners, and they should be independent! We need clinics with teams for all our patients! And, btw, doctors are people, too, so they need a very definite work week so they can be with their family and have enjoyable lives - so that means they can't be tied down to patients, rounds, call, etc.! (Okay, that last one is unfair, but I'm leaving it in anyway.)

Well, as my old roommate from Caribou, Maine used to say, bulldiggy. With all the money going to the money pit of hospitals and anesthesiologists (starting at $600K around here) and cardiologists and ortho and imaging (many with millions each year), what we want to economize on is primary care? You've got to be out of your mind!! We're great, we are what's needed, and the system needs to be based on us! We are the biggest bargains in the medical care arena, and you want to cut us??? We love our PNP's - they are great - but they ain't doctors, buddy. We're going to direct all the doctors to be these same specialists who are causing all the ICU problems, those emotionally dead souls, or at least confused? Give me a break!

OK, I know, I shouldn't be on the fence so much, you should know where I stand. OK. Next post I'll take a stand.

Budd Shenkin

Sunday, August 8, 2010

Turkey and Anti-Semitism - It Could be Scary

I’ve never been one to spot anti-Semitism near and far. Nor to overlook it.

I was raised a secular Jew and remain one, married twice, each time to a shiksa, and my kids view themselves as half-Jewish, which you can be if Judaism is a nationality and a cultural heritage rather than a religion. I try to be dispassionate in matters concerning Israel, but I have to admit I feel a rush of nationalism with each war or skirmish. I do know where my loyalties lie, but I am critical of the political structure of Israel, their policies, the predominance of religious conservatives, personal arrogance of many Israelis, and cruelty towards Palestinians by troops and some policies, even given the obvious provocations. I support the Gaza incursion – rockets cannot be disregarded. So I tend to hang with J-Street, the alternative to the very conservative, very nationalistic AIPAC.

I’m just trying to locate myself as a reporter for what I have just found in our trip to the Black Sea and to Istanbul.

When traveling, I like to read the local English language press. It usually is boosterish, often amateurish and provincial, and I’m never sure where it comes from, but I read it. At least you get to hear what’s in the air. Last year I read the English language newspaper in Dubai, which were boosterish. Didn’t say much about sovereign funds, as I remember. Last week we were in Istanbul for a couple of days, and I read the Hürriet Daily News. They covered Recip Tayyib Erdoğan, Prime Minister since 2003, head of the Islamist Peace and Development Party. From his Wikipedia entry:

As prime minister, Erdoğan implemented numerous reforms within a period of time. After 45 years, the negotiations for Turkey's accession to the EU started during Erdoğan's tenure. A great deal was achieved in democratization, attaining transparency, and preventing corruption. Parallel to this, inflation, which had for decades adversely affected the country's economy, was taken under control and the Turkish Lira retrieved its former prestige through the elimination of six zeros. Interest rates for public borrowings were pulled down; per capita income grew significantly. The AK party won the elections of 2007 making it the first time in 52 years that a party in power has increased its votes for a second term.

Of course, what isn’t mentioned is that he was an apparent supporter of the very provocative Gaza flotilla last month that Israel botched so terribly, succumbing to the provocation. Where has that vaunted Israeli ability gone, anyway? On the way to becoming just another Middle East country, I hope not?

The Hürriet Daily News featured an apparent ongoing conflict between the government and the armed forces. Turkey it has often been said, is not a country with a military, but a military with a country. Since the time of Ataturk, the military has led in modernization and secularization – so I’ve always been for it. Now, however, the Hürriet Daily News reports that the government wants the military to be led by civilian government, which would be ho-hum in any other country. That’s the way it seemed to be treated by the Hürriet Daily News, but this is Turkey, and Turkish civilian-military relations cannot be treated that way. So it was curious that the Hürriet Daily News seemed to be treating it that way.

What, in fact, is Erdoğan’s deal? His party is Islamist. He won power partly because of the former ruling coalition’s incompetence and corruption, but there is an Islamist tide in the world. There is more Islamic dress observed in Turkey than previously, and more religious orthodoxy.

Is the Erdoğan government pushing for geopolitical advantage from its crossroads position and it’s 8% economic growth per year? Or is there some true ideology involved? Was the posing with Ahmadinijad and voting against UN Iranian sanctions geopolitical, internal political, or ideological? Or reaction to being turned down by the EU, especially by France, which is having its own Islamic problems now?

Nothing is simple. After all, A.J.P. Taylor, perhaps the greatest English historian of the past generation argued that Hitler was actually a traditional politician in his aims and means – minus the Holocaust, I would assume – I have to reread that book, which I just saw in my bookshelf yesterday, actually. So the best leaders mix their aims and goals for maximum advantage. As Aaron Wildavsky used to say, never do anything for one reason only, even though he was only talking about academics.

But here is what else I saw in the Hürriet Daily News. Erdoğan declared that Turkey, Hamas, and others could not get their true story told because the worldwide media is controlled by Jews. He also said that the PKK, Kurdish separatist guerillas which has resisted Turkish repression for years, are agents of their Jewish and Israeli paymasters.

This material is unreported in our press, as far as I can see. If it has some validity, that this is what he is really saying, this is really some serious anti-Semitic shit. Next thing we’ll be hearing is the Protocols of Zion, the notorious Russian forgery of the secret Jewish plot to take over the world. Next thing we’ll be hearing is Holocaust denial from him.

As I say, I’m a secular Jew, and I’m pretty assimilated. I don’t look for anti-Semitism under every stone. I support Israel but only with reservations. But I also know, anti-Semitism is always there, ready to be reinvigorated. It lives and thrives in the European Left Wing and academia. And I know you can’t let anti-Semitism just burn itself out, because it won’t. Just like in a political campaign, you have to hit back early and often.

There is always more than meets the eye. The Israelis sure know what is going on, and they are in negotiations with Turkey, their best partner in the Muslim world. If Turkey really wants to grow, being able to trade with Israel and benefit from that vibrant economy is a better deal than the stagnation in other places, such as Iran. So I’m not jumping to conclusions.

But if this is accurate reporting, and this is really what he said – isn’t this dangerous? If this is true, if he is really saying these things, if the Hürriet Daily News has any validity at all – this is very scary stuff.

Budd Shenkin