November 26, 2024

I haven’t written a long post in a week and a half so I suppose I better break out the laptop, move the cat out of the way before he can walk over the keyboard and screw it up again and let my fingers do the walking as I download some of the things currently rattling around my brain. This is going to be one of those just start writing and see where it goes entries. Sometimes I have a plan with specific points I want to make. Sometimes it gets vomited up whole from some dark place in my interior. Sometimes it’s random stuff that bubbles up and then gets connected to the next topic through the weird tangents that my mind tends to create. I think this is one of the latter.

A friend asked me earlier this week why I tend to keep myself so busy trying to keep all of the balls in the air and all of the various activities balanced. This week, for instance, I have usual work issues, a legal case to finish reviewing, the last few runs of Little Women before tech is upon us, a need to finish a rough outline of the new book, and various social obligations. My answer was to say I really have two choices. I can either keep myself busy and engaged and structured with my time well accounted for or I can sit in my bedroom and scream into the void. And the former seems to be more productive.

I, of course, continue to read the political news (my moratorium on consuming any televised news programs continues) and roll my eyes at the choices of leadership being announced by the incoming administration. No one is asking my opinion on any of this so I, like the rest of the country, will have to learn to live with what is imposed upon us. That’s the way our political system works. If we don’t like it, we’ll have to get off our collective butts and change it but I don’t see that happening in a society that’s either narcotized by the proverbial bread and circuses or leading lives of quite desperation in the cycles of continual debt that late stage vulture capitalism is forcing upon the majority of the younger working population. The one thing I won’t do, however, is dismiss the worst ideas coming out of the new regime as simply being political rhetoric. One of the first rules of dealing with authoritarians is believe what they tell you the first time. I find myself time and again going back to Masha Gessen’s 2016 essay ‘Autocracy: Rules of Survival’ written at the time of Trump’s first election. She’s expanded it into book form in the intervening years and should be required reading, but won’t be.

I am approaching the next six months in my medical career cautiously. I have no idea which poorly thought out ideas will or will not become government mandates and in what order. I will remain at my post as long as I am not asked to compromise my personal or professional ethical codes and continue to deliver the highest quality care possible within the constraints of a changing and collapsing system. Will I be able to continue to work for a few more years as planned? That remains unknown. Here are some of the more serious issues I see coming down the pike.

1. The continued erosion, if not the downright destruction of the public health system. Various political actors, mainly with no real knowledge of how science of healthcare actually work, remain upset by what they see as chicanery around the pandemic shutdowns and vaccinations. As our public health system is highly fractured between states, counties, and municipalities, none is big enough to withstand coordinated attacks for long and it will be fairly easy for significant defunding of programs. There are new pathogens always waiting just around the corner for just the right conditions to allow for a new outbreak. H5N1 influenza, which can have up to a 50% mortality rate in humans, has been spreading in the dairy and poultry industries. There have been sporadic human cases which may have been caused by human to human contact. We don’t have the conditions yet for a major event but just the right mutation could change that rapidly.

2. Endangered academic health centers. Medical schools are finely tuned ecosystems depending on flows of funds from the federal level, mainly for research through the NIH and education/clinical care through Medicare and, to a lesser extent, Medicaid. Many of the expenditures made might, to an untrained eye, look spurious or like a waste but science depends on a certain amount of free inquiry. We have antibiotics because Alexander Fleming got interested in a moldy orange. A DOGE bureaucrat, thinking that the modern equivalent of the study of rotting citrus is not useful, could completely upend decades of work and potential new advances without understanding what they are doing. It won’t take a lot of redirected or removed funds to push these institutions towards insolvency in their current form.

3. Disavowal of science for common wisdom. Dr. Mehmet Oz looks to become the new director of CMS which administers Medicare and Medicaid. These are huge government programs and Medicare in particular is the 600 pound gorilla around which the whole health care system revolves. Dr. Oz is personable and presents a lot of carefully calibrated ‘common sense’ in his media appearances. Unfortunately, when you look over time at what he advocates, 40-45% of his recommendations have no medical or scientific basis and another 15-20% are the opposite of what medicine and science have shown to be true. I use plenty of common sense in my practice, but I temper it with what I know has good science behind it, otherwise I might be bleeding people, using leeches, and refusing to wash my hands (all things that were accepted common sense in their day).

4. Inability to provide care. A crackdown on immigration is going to decimate the already limited pink collar work force from which the day to day workers in nursing homes and other senior care institutions are drawn. As most of these businesses have been purchased over the last two decades by conglomerates for a purpose of profit, they will be closed down if they prove unprofitable, either because of a need to pay higher salaries than business plans intend or because of fewer paying customers due to a collapse in quality or other factors. No senior living facilities, than middle America will have to figure out who takes the elders in and who has to remove themselves from the workforce to provide the care at home.

5. Continued societal denial of aging. As the World War II generation is nearly completely gone and the Silent generation is predominantly in their 80s and 90s, the Baby Boom will be moving into their aged years rapidly (13 months to go before they hit their 80th birthday). They have denied the realities of aging for decades and I don’t see them embracing them now and will likely try to arm themselves for a war against inevitability which they will lose as has every other generation that has come before them but with what collateral damage to societal institutions and younger generations.

But not all is bad. I’ve been to the theater a few times. The new movie version of Wicked is out and I’ll get to see it this weekend and I have to put on some holiday clothes and head out to a tree lighting ceremony soon. I’m going to focus on the good stuff.

Get up. Get dressed. Go out. Do good.

(A friend asked if he could sell T-shirts with this, my latest mantra on them. I said why not? If they come to market, I’ll post a link…)