The New Medicine

This morning I spoke with a nurse who is in the University of Massachusetts Lowell nurse practitioner program. She is 25 years old and has been working on a ward at a community hospital and says, "I can't see doing that at age 40. I'm exhausted when I get home at night."

She is taking course work at the university and expects to have her NP certification in two years, 2020.
She got her BA in nursing in 2017.
I asked where she will do her clinical training and she smiled and said, "That's the problem. I have to arrange for my own."
"What? You mean with a doctor?"
"Or with another nurse practitioner."
"But how do you know if they are any good?"
"That's what I'd like to know," she said.
The clinical rotation covers 6-9 months, sometimes a year, but it is not clear how many hours a day this means. As a working floor nurse working 8 hour shifts, presumably the clinical rotation will not be 8 hour days.

At one of our clinics, all the primary care doctors quit and the manager, a thirty something woman with a MBA told me that really would not be a problem. They can always find nurse practitioners or physicians assistance to see patients. The doctor who signs off on their patients does not have to be on the premises, in fact will be about 10 miles away seeing his own patients.

I considered how I learned about patient care. It's true, I did not have much direct training dealing with patients who were not critically ill. We had a weekly outpatient clinic which most of my fellow residents thought a waste of time because the patients really didn't have much wrong with them, as opposed to the patients we saw in the hospital who often had several things wrong with them, each competing to see who could kill the patient first. I didn't mind the clinic, though. I got to see the patients I had seen in the hospital in follow up and it was amazing how healthy and normal they looked. Gratifying really. Some of those folks we wondered why we were working so hard to save, they looked so damaged, but then, six months later they looked like normal human beings.

Being exposed to people who turned out to have leukemia, or colon cancer or lung cancer or serious vascular disease or heart attacks or new onset diabetes for four years taught me a lot about how innocent sounding symptoms could be the harbinger of serious underlying illness.


It also made me respect influenza, strep pharyngitis and pneumonia, which occasionally landed a patient in the hospital where sometimes we could not save them.

How a nurse with 6 months of "shadowing" another nurse practitioner could step into the world with that kind of preparation, I could l only imagine.
She will look like a doctor, with a white lab coat, a stethoscope around her neck and many of her patients will not actually understand she is not an MD but she will know.


Fact is, she will be "cost effective" for the MBA who manages the clinic: Her salary will make those Excel spread sheets for the clinic's income and overhead look good.

New Hampshire At Risk? Merrill, Childs and Francese

The gathering storm which is New Hampshire demographics was explored in a 2008 documentary by Lorraine Stuart Merrill, Jay Childs and Peter Francese, called "Communities & Consequences" which depicted the state as aging--we are the second oldest state in terms of age of the people living here, and we have a problem  of young people moving away rather than settling here.

I have not seen the original film nor the sequel which is in production, a follow up exploring the lack of affordable housing, land development abuses and decline in school, health care and effective local governance.

3 bridges over Piscataqua at Portsmouth

I've only lived in the Granite State 10 years, a veritable new comer, but most of the problems I see seem to be problems of scale. Only 1.3 million people live here, and they are not evenly distributed, being mostly clustered near the Massachusetts border or along the seacoast.

Tugboats at Portsmouth

This is a state which until recently has been mostly rural, apart from the mill towns of Manchester and New Market and its legislature is decidedly and determinedly amateur. It is only of the largest legislatures in the free world, 495 Representatives, for a state of diminutive size. 

North Church, home to Daniel Webster

If the people of New Hampshire wanted to improve health care, they would have to recognize that given the cost of health care, they simply do not have enough people to support a first rate system. Even Vermont, which tried to create a state run health care system found it simply did not have enough people to support one.

Fall stream 

For problems like health care, likely New Hampshire would have to form a consortium with other states--the obvious partners Vermont, Maine and possibly Massachusetts. Then the folks of New Hampshire would have enough market clout to buy itself a better system. Unless, of course, Bernie Sanders got swept into the Presidency with enough legislators to put in a National Health system.

Lake Winnipesaukie 

But what really draws young folks to a state and keeps them there is an educational system.  

New Hampshire will never have an adequate supply of really well trained doctors until it has university hospital training programs here. Young doctors tend to stay close to where they are trained as interns, residents and fellows. 

Rte 1A Rye, NH

Rhode Island does not have a problem attracting young folks because it has three thriving universities, only one of which is a public, state university. 

The University of New Hampshire has attracted to its mother ship a faculty with glittering credentials, and the colleges at Keene and Plymouth have stars, but to really bolster community building, a lot more money would have to pour into these institutions. 

White Mountains

Until 2017, one could always say, "Never gonna happen." Nobody is going to allow the kind of spending which would be needed to prime that pump. Republicans would shout down spending with the dreaded, "Deficits, Debt and Doom!" 

Now, of course, none of that dreaded triple D seems to matter. As long as the deficit emanates from cutting corporate taxes, it's all good. Apparently, the deficit is not the problem. Debt is not a problem. It's the moral significance of how you got there.

Or something. I don't quite understand. 

Portsmouth from the Piscataqua River

There are some very smart people living in New Hampshire, but they have not, thus far, outweighed people of the other variety: the entrenched, the ignorant and the fearful. 

As Rhode Island discovered some years ago, the solutions have to originate from within, from long time Granite Staters who have street cred with the folks from Bedford, Kingston and Franconia.  

Plaice Cove, Obadiah Youngblood

New Hampshire is one of those places that has so much going for it, you wonder how the folks here have managed to resist becoming the most gentrified state in the union: Gorgeous lakes, a splendid coastline, proximity to the cerebral cortex of the nation, good connections to rail, sea and land transport. Two airports which could burgeon if allowed--one in Manchester and one on the seacoast. 

The wonder is how we have managed to remain somnolent when the world has been clamoring all around us. 

Rte 1A North Hampton, NH 

Where Are the Winners for Democrats?

One of the wonderful things about New Hampshire is it is small enough so you feel involved; you are not swept aside by crowds.

There are 7 contestants for the Democratic nomination for Carol Shea Porter's United States House of Representatives seat. 

So far, I've listened to  two. 
So far I've seen placidity and passion, but where is that one with the cunning and the smarts to be able to beat the Republican?

Less Than a Year in New Hampshire 

Last night, at the Hampton Dems meeting, Maura Sullivan and Chris Pappas spoke.

I had heard Pappas before but was disappointed when he was challenged with a question about how he would answer the Trump-hole candidate who would say we need a Republican to build the wall and keep dark skinned illegals from flooding in from Mexico and raping our white women. 
Pappas replied he didn't want to get into "food fights" about that. 
When that was followed by a moment of pregnant silence, he explained that he was offering the alternative of civility and it was his judgment that more New Hampshire voters are offended by the nativism and hate than are drawn to it.

Not Up For a Fight

Thinking about the razor thin margin of the 2016 elections in New Hampshire, I remained unconvinced. 
I think we have to win not only the open minded Democratic base, but we have to appeal to the Republican voting sorts who might vote democratic if they thought they had someone who had some spine. 
Chris Pappas is thirty something, owns and runs a family restaurant and is warm and fuzzy. 
I don't think warm and fuzzy can win this time.

But Can She Fight on the Floor of Congress?

Maura Sullivan is another thirty something, but she has something different to sell: She was a Marine Corps captain and I was hoping for a steely eyed killer from the sands of Iraq, but what I heard was an emotional appeal, short on detail.

In one telling exchange, she was asked about the "#Me Too" movement. She was clearly caught off guard and asked the question to be repeated, as if she had never heard of the #Me Too movement or, if she had, she could not see how it would be relevant to a Congressional campaign. 
Well, Elizabeth Warren has endorsed it; lots of Congresswomen have embraced it,  but what do you think about it? 
What followed was a prolonged expostulation about how appalled Cpt. Sullivan is to have to even address the issue of sexual harassment. How very appalling it is that women who have to struggle with the deployments of their husbands might be sexually harassed around the Paris Island base.

The problem with all this is what it revealed about Cpt. Sullivan: 
A/ She was unprepared for an au currant question for which she should have been well prepared.
B/ She showed no capacity to explore both sides of a question.

She is young, blonde, has been a Marine officer and she is trying to sell that as the reason she should represent New Hampshire in Congress, but you are not going to be carrying an M-16 in Washington. 
You have to serve with your mind. 

What I was looking for was the requisite statement about Ms. Sullivan's basic sympathy with the women who have been unjustly violated, either physically or mentally, but then a discussion of the risks of giving up on legal remedies, the risks of simply dismissing the right of the accused to face and cross examine his accuser, the risk of this movement degenerating into vigilante lynch mob mentality.
Anyone who has read the New York Times or any of a variety of sources would have seen the full discussion of this topic with comments supporting and attacking #MeToo.

But she showed no capacity, no preparation for that sort of analysis. 
Sullivan would be chewed up and spit out by a truly cunning and pugnacious Republican, who would say, "Hey, I'm all for protecting women. There's no way we can have a work force which is half women being subjugated by dim witted men hitting on them. 
But, on the other hand, there have been famous instances of false accusations and miscarriages of justice--the Duke Lacrosse team, the Rolling Stone fake rape at UVA are only the two most famous. 
As the feminist author, Margaret Atwood, has said, there can be no women's rights without rights, period. When you get to the point where accusation by itself is tantamount to conviction, then you have accepted mob rule."

If that happened in a candidates' debate, Ms. Sullivan would be toast.

So, we have two down and five to go. So far, the prospects have not been encouraging.

"Me Too" and the Logic of the Vigilante

Women have been harassed in many ways at the workplace, from outright rape to far less aggressive ways, comments about their bodies, their scents, or simply comments from men about their own desire for those women who have to work with them every day.

Atwood

The "Me Too" movement has succeeded in raising awareness of this serious and pervasive problem.


But "Me Too" has also embraced a mode of the vigilante--punishment without trial.
The argument made by "Me Too" advocates has been the legal system, and corporate systems run by Human Resources, have failed to protect women and failed to deliver justice, and given the failure of established institutions to redress their grievances, women are justified in going to the press, to social media to exact revenge by public shaming.


This is always the way with the vigilante: The argument almost always involves at least three elements:
1/ The established process of judges, juries and trials is too slow.
2/ The legal system often fails to convict guilty parties, who get off "scot free."
3/ Women need protection, but the legal system in its failure to protect is complicit in the crime.

"The Oxbow Incident," written decades ago, shows how this can play out. In the end, three innocent men are hanged for a crime which, it turns out, was never committed.


As Margaret Atwood has asked: "Do Good Feminists believe that only women should have such rights?"  She adds, "I believe that in order to have civil and human rights for women there have to be civil and human rights, period, including the right to fundamental justice."


Yet, that is exactly what the "Me Too" women would deny the men they've accused.
Atwood outraged "Me Too" by referring to a witch hunt.
"There are, at present, three kinds of "witch" language. 1/ Calling someone a witch, as applied lavishly to Hilary Clinton during the recent election. 2/"Witchhunt," used to imply that someone is looking for something that doesn't exist. 3/ The structure of the Salem witchcraft trials in which you were guilty because being accused.  I was talking about the third use."

Accusation is Final Judgment

She goes on to note that Me Too is a symptom of a broken legal system. I would add that it is the symptom of the perception of a broken legal system. Doctors and many swept up into the criminal justice system have known for decades our justice system is any thing but.


"All too frequently, women...couldn't get a fair hearing through institutions including corporate structures--so they used a new tool: the internet...This has been very effective, and has been seen as a massive wake up call. But what next? If the legal system is bypassed because it is seen as ineffectual, what will take its place? Who will be the new power brokers?"


Will we have tumbrils rolling through the streets of Hollywood and New York and Madame Dufarge knitting names into her cloth?

Duke Lacrosse Falsely Accused

Examples of false accusations have been noted: The UVA fraternity rape that wasn't; the Duke lacrosse team rapists who committed no rape and no crime; the comedian whose accuser went home with him, got naked and didn't like what followed.

Lurid detail. Lies.

And then there is the case of Al Franken, who was likely boorish, stupid, unfunny but hardly a rapist or even much of a bully. More a stupid adolescent who has no idea how to approach women in a way which they might find attractive, not to mention acceptable.


The very range of complaint, from the man who puts up a Playboy pin up at his work station next to the work station of his female coworker, is hardly the same sort of harasser as  the TV star who has a button on his desk which locks the door to his office, so the woman cannot escape and he can rape her. Those are two very different offenses in my mind, but not, apparently in the mind of Me Too.


Some Me Too folks say it's not even the individual man who is the problem but the systematic oppression of women by a patriarchy. Really? Where are we now?


Those who argue the airing of accusations in the press is just, argue that in the respectable press, the accused are given the opportunity to respond, but thus far most of those accused have not denied the accusations, which proves they are guilty. Of course, those who refuse to comment have likely been admonished by their lawyers to say nothing, presumably because even the innocent in denying inexpertly may open themselves up to new charges.


In the case of Harvey Weinstein, we had that old "I'm entering therapy" which is in fact, an admission of guilt,  at least to some of the charges. But in the case of Al Franken his denial was that he remembered things differently, and that was taken as an admission of guilt as well.


Hardly.


The other Me Too trope is while there have been some clear instances of women bearing false witness and accusing men who had not wronged them, those unjustly strung up in the court of public opinion are "collateral damage," and their fate is justified by the need for revenge on the part of all those women who have been wronged for whom there was no other option to seek justice.


The result has been, to my eye, something akin to mob justice. That is the alternative to a dysfunctional legal system.


An accusation of harassment must be taken as a substantial act, an act of aggression. It may be warranted, but it is aggressive. It should be subject to question, to cross examination. In any system of adjudication, the punishment and judgment should fit the level of offense: The rapist belongs behind bars; the guy who puts up the Playboy pin up is a jerk, but does not belong behind bars.


What you have to ask yourself is this: Can a legal system be fixed, improved, righted? 


Then ask: Can mob rule ever be made just?


So it comes down to this: Do you prefer law or the mob?

Hideous Memories. Beautiful Songs.

When Sarah Vowell described the story of America as hideous memories with beautiful songs, she knew of what she spoke.

Certainly, among us today are people who remember John F. Kennedy's assassination in hideous Dallas, in 1963. His assassin may have been a dissolute loner named Lee Harvey Oswald, but many believe Oswald was an innocent fall guy and that Kennedy was assassinated by a conspiracy, possibly involving Mafia hit men. No matter, it was hideous and lunatics were involved. 

General James A. Garfield

Lincoln, of course, was shot in the back of the head by another lunatic, a self dramatizing out of work actor, who shot Lincoln, slashed an accompanying officer and then leapt to the stage, shouting, "Sic Semper Tyranis!" thus always to tyrants, before fleeing. Another hideous memory.

Between those two assassinations another President was shot, just a year into office, and before he could make any mark in history.  James A. Garfield had been a true war hero, in the Civil War, which ended only 16 years before he took the oath of office. He was nominated when the Republican convention deadlocked, torn asunder by the boss of the New York party, who thought he deserved to be running the government, and would have been had his candidate been nominated. 

President James A. Garfield

Garfield may have been the finest mind since Lincoln, and certainly one of the most admirable men to have ever been elected President. 

His inauguration speech was--outside of Lincoln's two addresses--the finest or among the finest ever given.

After a brief summation of the history of this nation, in which he put our struggles into a moral and emotional framework, he turned to the problems which his administration had to face, among them the unfinished work of freeing the former slaves, who without education and help could never be really free, he noted.

He knew he had to address the spoils system of government and replace it with a Civil Service whose job it was to serve the people not simply to be paid off for services rendered to victorious candidates.

He pointed to the financial underpinings of democracy which entailed decisions about whether to back American currency with gold or not.

And he turned to the issue of racism, and colored folks in the crowd stood weeping as he highlighted the importance of this work:

The supremacy of the nation and its laws should be no longer a subject of debate. That discussion, which for half a century threatened the existence of the Union, was closed at last in the high court of war by a decree from which there is no appeal—that the Constitution and the laws made in pursuance thereof are and shall continue to be the supreme law of the land, binding alike upon the States and the people. This decree does not disturb the autonomy of the States nor interfere with any of their necessary rights of local self-government, but it does fix and establish the permanent supremacy of the Union.	9
The will of the nation, speaking with the voice of battle and through the amended Constitution, has fulfilled the great promise of 1776 by proclaiming "liberty throughout the land to all the inhabitants thereof."	10
The elevation of the negro race from slavery to the full rights of citizenship is the most important political change we have known since the adoption of the Constitution of 1787. NO thoughtful man can fail to appreciate its beneficent effect upon our institutions and people. It has freed us from the perpetual danger of war and dissolution. It has added immensely to the moral and industrial forces of our people. It has liberated the master as well as the slave from a relation which wronged and enfeebled both. It has surrendered to their own guardianship the manhood of more than 5,000,000 people, and has opened to each one of them a career of freedom and usefulness. It has given new inspiration to the power of self-help in both races by making labor more honorable to the one and more necessary to the other. The influence of this force will grow greater and bear richer fruit with the coming years.	11
No doubt this great change has caused serious disturbance to our Southern communities. This is to be deplored, though it was perhaps unavoidable. But those who resisted the change should remember that under our institutions there was no middle ground for the negro race between slavery and equal citizenship. There can be no permanent disfranchised peasantry in the United States. Freedom can never yield its fullness of blessings so long as the law or its administration places the smallest obstacle in the pathway of any virtuous citizen.	12
The emancipated race has already made remarkable progress. With unquestioning devotion to the Union, with a patience and gentleness not born of fear, they have "followed the light as God gave them to see the light."

Had he been successful in solving these problems, we might have been spared the Jim Crow years in the South and much heartache, but he was shot by a man who was clearly a lunatic, whose family had hoped to commit to an insane 

but who, as is understandable to us today, managed to get a gun.

Garfield's lunatic assassin 

Such is American history: the great, the less than great and the potentially great wiped out by the weirdest and most diseased among us.

Senator Patrick Leahy on Nothwithstanding Clause and Funding Rapists

Rachel Martin interviewed Senator Patrick Leahy about a report that says the United States Congress is still funding Afghan police units which are known to systematically rape young boys, who they seem to have a predilection for raping.

In our country, if you have child porn on your computer you can go to prison for the rest of your life, but our Congress is funding real live child rapists in Afghanistan, and has been for some years.

Ex-Captain Daniel Quinn

Daniel Quinn, an Army officer in Afghanistan was relieved of his command because he beat the daylights out of an Afghan police commander who liked to chain village boys to his bed and rape them all night. That was more than Quinn could stomach, but his American superiors scolded him, reprimanded him and ultimately ended his career for giving vent to his outrage in a most unsoldierly manner.

“The reason we were here is because we heard the terrible things the Taliban were doing to people, how they were taking away human rights,” said Dan Quinn, a former Special Forces captain who beat up an American-backed militia commander for keeping a boy chained to his bed as a sex slave. “But we were putting people into power who would do things that were worse than the Taliban did — that was something village elders voiced to me.”
--NYT article 

But America is still at it, still making bargins with the devil. Here's an exchange from NPR:

RACHEL MARTIN, HOST:

The abuses include the routine enslavement and sexual abuse of underage boys by Afghan military commanders. Senator Patrick Leahy wrote a law requiring the Pentagon to stop funding foreign military groups who commit human rights abuses. But in Afghanistan, that has not happened.

INSKEEP: The Pentagon explains this by citing language tucked into a funding bill called the notwithstanding clause as justification. Notwithstanding other issues, the funding continues.

David Greene spoke with Senator Leahy about the inspector general's report. And we should warn you, the details in this interview will be disturbing to some.

PATRICK LEAHY: I can't imagine walking down Main Street - certainly in any town in Vermont - and say, how would you like to have your tax dollars spent to support a military unit that will take young boys, dress them up as girls and then use them as sex slaves? That's exactly what's happening.

Not Even Original

George Templeton Strong, a diarist and lawyer, who is widely quoted in histories of 19th century America, particularly in the Ken Burns series on the Civil War and in Chernow's "Grant" described one of the two scoundrels who were able to hoodwink the gullible President Grant into a variety of shady schemes, a man named Jim Fisk.

In a long line of husksters

Chernow describes him as handsome, blonde, bloated with diamond rings and "flashy." 

But it is Strong's description which is eerily familiar:

"Illiterate, vulgar, unprincipled, profligate, always making himself conspicuously ridiculous by some piece of flagrant ostentation, he was, nevertheless, freehanded with his stolen money, and possessed, moreover, a certain magnetism of geniality, that attracted to him people who were not particular about the decency of their associates."

Chernow adds:
He collected prostitutes and chorus girls no less promiscuously than he bought railroads and steamships and exulted in the attention his flamboyance aroused."

If any of this sounds familiar, it should at least remind us that today's version of Big Jim Fisk isn't even original.