IF THERE WERE JUSTICE ...

 

You have heard this song.

Arlo Guthrie made it famous. When he does it, the audiences all sing it in harmony, in the refrains.

Willie Nelson, Cheryl Crowe, Glenn Campbell, John Fogarty everyone has done it.

But Steve Goodman, who I have never heard of, and who I bet you have never heard of, wrote and performed it, and listen to his guitar!

He wrote the song, as Arlo Guthrie clearly told the story, and Goodman's version, for my money, is by far the best ever done. But who has ever heard him do it?

https://www.youtube.com/watch?v=e4ztWNJYFrU

Reunion

 

We graduated when we were 26 years old and now 51 years later, about 40 of 90 graduates of the Cornell University Medical College convened at the University Club, in New York City, for dinner.

Each graduate, and if present, each spouse, was asked to get up and summarize his career, fate, life since we last saw each other. (I can use the proper "his" because there was only one woman graduate and I'm sure she'll forgive my antiquated grammar.) Dinner was getting cold, waiting to be served.

A man at my table had returned to Montana/North Dakota, become chief of Obstetrics at the then new North Dakota medical school where he still serves today, although he stopped delivering babies at age 70. Along the way he bought and sold a few banks, built hundreds of homes and office buildings as a sideline.

Another became plastic surgeon to the stars in Hollywood.

A few did most administrative stuff: one had organized the government's efforts to deal with HIV, as he worked first at the CDC, and later in the American program to fight HIV globally. Another reshaped medical school curricula, and helped organize and found a new Canadian medical school.  Someone else made an infectious disease career in the diabetic foot, but that took him to a professorship at Oxford and he authored numerous books and papers. Two others became founding fathers of Emergency Medicine--when we graduated there was no specialty of Emergency Medicine--one in Arizona and one in Washington State. The latter organized a company to sell Emergency Medicine groups to hospitals and today many hospitals contract out their ER departments to his organization, which is the largest employer of ER doctors in the country. The same guy got an MFA from the University of California and made a documentary about ER medicine. 

There was an astonishing story about the one woman: She was the wife of a Cornell first year, and she was attending NYU medical  school, and she wanted to join her husband and she was told that because one of the 5 women in the class was leaving, there was now a "woman's spot" available. Looking back at the classes since 1945, there had always been either 4 or 5 women in every class of 90. During the war years, the classes had 50 women but then reverted to 5 after the war ended. The men who ran the admission committee had no qualms about quotas. Until the 1960's there were only 5 Jewish names and 1 Black. When you think about the ills of "affirmative action" you have to consider how many years there was affirmative action for White Christian males.

As it happened, I was the last doctor to speak and all I could say was that I was inspired to go into Endocrinology by a pediatric endocrinologist named Maria New, who everyone there knew, and Maria, having come from a family of professional musicians, realized that unless you are the very best, there is no point in trying to be a musician, so she chose medicine because that's a field where even if you were mediocre, you could still do a lot of good and make a decent living. (Of course, coming from Maria, that was funny, because she was among the very best of pediatric endocrinologists, and did several ground breaking studies.) So, I said I had practiced endocrine, first in private practice, and now for a corporation, and I presided over a mediocre practice, although I've gotten progressively better at it, but after more than 50 years of practice I've probably done more good than harm, in a mediocre sort of way.

What was more impressive to me than the curriculum vitae of those who attended, was the fate of ten classmates who could not attend because they were dead. Some died young, one from suicide, one from an accident, others from causes unknown. Several of their wives, who I remembered clearly from medical school days, had died young, one from breast cancer at age 39. 

Most had made enough money for beach homes, pied-a-terre apartments in New York City, and only one I could identify practiced, as I do now, in an underserved area with patients who are at the bottom end of the economic strata. 

There was a lot of talk about how we were taught to provide the best type of care--the importance of laying hands on the patient, of establishing a connection with the patient, all things which are now considered mere "theater," things which are unnecessary and self indulgent, because, after all, you can see a thyroid, examine a thyroid way better with a sonogram than with your fingers, so why bother touching a patient's neck?

A neurologist spoke of having patients presented to him by young doctors who never bothered with a physical exam, once so essential to figuring out where the brain tumor was, but instead now they present the brain CT or MRI, and never mentioned whether the patient was hemiplegic. 

One doctor told how he had been told to evaluate a patient at Cornell, as a student, and he had done what he thought was a complete history and physical exam but after he presented the patient to his professor, the professor asked if he knew who the patient was, or what she did in life and he had to admit he did not. He knew she had pneumonia. And the professor said, "The patient is Aretha Franklin. Next time don't forget to do the 'Social History' (SH) part of the work up." (It is the SH where you ask where the patient was born, grew up, got educated, what kind of work they did and marital status and where they live now.)

Now, of course, that "Social History" is given short shrift, and young doctors refer to it dismissively because it takes time, and when you are trying to see 30 patients in eight hours, that means roughly 15 minutes a patient and there are a lot of labs and imaging studies to review during that time.

When I arrived at my job in New Hampshire, I found there were no examining gowns. How was I going to examine a woman's heart without an exam gown?

"Why would you want to listen to her heart?" I was asked. "You're an endocrinologist!" 

I really had no answer, other than that's the way I always had practiced medicine, the way I learned it, and I really could not remember why. 

Well, now I know why: because that's the way I was taught. I might be the only doctor to see that patient for a year, and why miss a high blood pressure, atrial fibrillation or a melanoma because you were supposed to focus on just her thyroid, and then move the patient on to the next doctor--who she would likely never bother seeing? That in the flesh encounter is your last  chance to actually do the patient some  good.

At least now, I know where I got most of my bad, inefficient, self indulgent habits.

Trump Will Eat Your Pets!

Everybody's saying it. And I saw it on TV, so it must be true.

All those ketchup ladened French Fries thrown against the wall, were part of a special "Cat and Dog" dish he likes.

And there are miles of caravans, thousands of criminals and insane asylum escapees headed your way, especially if you live in Michigan, Pennsylvania, Georgia or Arizona all because they want to go to his massive rallies, which are bigger than any rallies in the history of the world and definitely not boring. 

Those are the best places for out-of-staters to feast. Ohio was just the beginning.

South Carolinians are crossing the border into North Carolina and not the best ones--they don't send their best; they send the pet eaters.

And don't get me started on Maryland, which is where, you know, the Wire happened, and all those bodies wound up in the vacant houses and Hannibal Lecter had a field day. Jodie Foster was lucky to escape with her life. Oh, lovely Jodie. Poor Jodie, you know she was a child hooker before she became an FBI agent? Very sad. And Maryland shares a border with Pennsylvania: Marylanders are just pouring across that Southern border into Pennsylvania by the thousands, looking for pets, and women, White women. They eat the pets and rape the women in Pennsylvania. 

Is Hillary out of jail yet? You know we didn't lock her up long enough. I bet she's headed to Springfield right now. She has a taste for a certain type of cat, I don't know which type, but she's a very nasty woman with a big cat appetite.

Did you know he could shoot someone on 5th Avenue and nobody would blink an eye and his fans would still vote for him? Everyone says so.

 He's done worse, really. Raping that woman, who was definitely not his type, in the back of that store and we won't even talk about Jeffrey Epstein, but you'd be surprised what we are finding out about him! That was the Clintons who did Jeffrey, who was a very nice guy. A good friend of Alan Dershowitz, you know.

And Alan just changed parties: He's no longer a Democrat. He couldn't stand being forced to eat dogs, which is what all Democrats do. But Republicans don't stop at the cats and dogs--they go after the children, or at least White children. White Christian children.

But the best part is, if you vote right, you'll never have to vote again, ever. Which is such a pain. Having to wait in line with all those foul, stinky immigrants the Democrats imported to vote for them but are now voting for Republicans, which is just so perfect. Really.

Really, I don't know why I bother. 

You can take a bullet for Democracy and all you get is complaints.

 

Justice vs Fairness

 What is the difference between justice and fairness?

The classic case concerns the five eight year old boys who decide they need a birthday cake for their party, and they assign one kid to bake it because he knows how and his house has a kitchen, which some of them are too poor to have, and they pitch in for the ingredients. They then ask him to cut the cake and they draw straws for the order of choosing, and he winds up getting the last choice of slices and cutting a cake in fifths, being difficult, he winds up with the smallest slice.

This is an example of fairness--each kid had a equal chance at a slice--but not justice, the baker argues.

He, after all, did more work, which should entitle him to the biggest slice. But the other kids argue he was assigned the task because he was lucky enough to be born rich and to have a kitchen. It was just to allow every kid an equal chance. But he says it was not just because he worked harder and contributed more. 

When we look at Republicans vs Democrats in America today, the typical Republican auto repair shop owner, or HVAC guy tends to see things from the point of view of the baker--I work harder and I should get more of the fruits of my labor. Why should I give away profit to those who did not work as hard?

Democrats tend to say: they never had a chance to work as hard and whatever comes out of a group effort should be evenly distributed, even if the workload is not evenly shared.

The doctor who owns his medical practice may complain about the share of the practice income he has to share with his secretary and with his nurse, especially as they work nine to five but he has to make rounds at the hospital after work and he is clearly the most valuable part of the enterprise.  The efforts of the staff are limited and the responsibility of meeting a payroll are not shared, nor are the responsibilities of meeting higher insurance and rent costs. The staff gets paid no matter what exigencies arise. The doctor has to figure out how to meet those exigencies and meet the payroll no matter what.

(For this reason 90% of American physicians--not surgeons--have given up private practice and are now employees getting W-2 forms as salaried employees.)

There is a wonderful scene in David Lean's movie, "Dr. Zhivago" when Zhivago finally arrives home from the war and he is met at the door to his family home, an imposing townhouse in Moscow, by a woman, an official of the new Communist regime, who informs him that his family now lives in two upstairs rooms in the house, and five other families now occupy the rest of the house. 

"Fifteen people now live in a house which once housed only five people," says the official archly.

"Oh, yes," replies Zhivago, "This is much more just."

The problem with justice, is it often means some individual is shafted.

Another scene, this one from "The West Wing"  when Jed Bartlet, then governor of New Hampshire,  is asked by a voter who owned a dairy farm, and who had voted for Bartlet twice, why Bartlet had vetoed a bill which would have raised milk prices and the voter felt betrayed. 

"Yep, I screwed you," Bartlet replied. "But it was either that or making milk prices unaffordable for the parents of poor kids; so, you make less money now, but kids can get their milk. If you want to vote for someone else, who'll put more money in your pockets, I can't blame you, but that would not be me."

So there you have it, fairness (act in the interest of the people who supported you) or justice--allow poor kids to get their milk.

Paper Boy

In my own life, the classic fairness vs justice story is well known in the family: One Christmas Eve my brother and I went out to collect the monthly payments for the Evening Star newspaper route owned by my brother (who was 12) but I delivered half of the route, for which I collected $3 a month, which he paid me out of the $18 a month the Star paid him. (At 7 years of age, I was too young to be employed by the Star. I was a subcontractor, serving at my brother's pleasure.)

On this particular night, my brother sent me to collect from one building he actually delivered in his half of the route. This was a neighborhood of "garden apartments," brick buildings built during World War II to house government workers who had flooded into Washington, D.C., just across the Potomac; each building had two apartments on each of three floors but there was only one customer who got his paper delivered in this particular building, and he lived on the third floor and my brother resented him, and did not want to hike up those three flights just to collect from that one door. So, I dutifully complied, racing up the stairs, ringing his door, and he appeared to find this breathless seven year old gasping out, "Collecting for the Star, sir."

He rummaged in his pockets and gave me the $3 for the bill and I gave him is receipt and said, "Merry Christmas," and slumped my shoulders dramatically, and slumped off down the stairs, slowly, piteously, hearing the door close behind me. But, by the time I reached the turn in the stairs at the second floor I hear the door open and, "Hey, kid!" and I went racing back up the stairs and the man held out a crisp $5 bill and said, "Merry Christmas, kid!" and I thanked him profusely and flew down the stairs to find my brother, retelling the whole story, flaunting the $5 bill, more money than I had ever held in my hand in my whole 7 year old life, dancing around, replaying how I had played it, slumped my shoulders like some Tiny Tim.

My brother snatched the bill from my hand and said, "That belongs to me."

"Why?"

"Because I delivered that guy's paper for the past twelve months, humping up those three flights of stairs and this is a tip for services rendered. It's my route and he's in the part of the route I deliver. It's only fair!"

That night we convened an emergency session of Family Court and, for once, I was not the defendant but the prosecutor/plaintiff. 

My father, sitting in his reading chair as usual heard the case as judge and jury, and my mother comprised the gallery, as always. Family Court was run according to standard rules of evidence, and the $5 bill lay on the coffee table, coveted by both the plaintiff and the defendant.

My father listened silently as I present the case, complete with a demonstration of slumped shoulders and how I had appealed to the Christian conscience of the customer and how I had played it, how I had walked slowly away to give him time to feel guilty at not having provided Tiny Tim with his Christmas turkey--that part evoked a suppressed laugh from my mother--and how he had responded to the whole act, and how it was the performance that accounted for his beneficence, not the twelve months of unwavering, reliable service as my brother argued.

My father asked for the defense summary, which my brother provided, without new arguments, simply saying it was his route, his customer and he deserved the tip which is a reward for faithful service,  not for collection drama.

My father did not look to my mother, but sat thinking, looking at his shoe tops.

"We cannot know the motivation of the customer," he said. "We do not have that critical testimony from that central witness, and thus we cannot know his motivation."

Thinking this was a case in which King Solomon really could split the baby, he said, "So, I'll give you $5," he told me, "And your brother can keep his $5."

"NO WAY!" I expostulated.  This had gone far beyond fairness. This was about justice!

I refused the $5, and my brother pocketed the bill and I did my best, until at least New Year's, to make him feel like Scrouge and he never spent that bill, as far as I know. He knew ill gotten gains when he saw it, and he knew fairness is not justice.

Prizes

 

Cornell University Medical College 50th year reunion

Schedule of Events: 9:30 AM to 11:00 AM: Presentation of Special Achievement Awards

Statement of the Nobel Prize Committee
Bob Dylan's songs are rooted in the rich tradition of American folk music and are influenced by the poets of modernism and the beatnik movement. Early on, Dylan’s lyrics incorporated social struggles and political protest. Love and religion are other important themes in his songs. His writing is often characterized by refined rhymes and it paints surprising, sometimes surreal imagery. Since his debut in 1962, he has repeatedly reinvented his songs and music. He has also written prose, including his memoirs Chronicles.

Tony Fauci graduated first in his class at Cornell University Medical School.

        "Someday, I will be either very rich or very famous. 

        But if I stay at Cornell, I'll be neither."

--attributed to Dr. Fauci

The 50th year reunion of my graduating class will be marked by dinners and events 51 years after our graduation in  few days. 

We started with 90 students, 4 women (one Black woman) and 1 Black man (who had blue eyes and blonde hair), although 2 of the women were gone after the first year.

This is an exercise of looking back, assessing what members of the class accomplished and, in a sense, a statement of the worth of that group and individual members of the class.

E Company of the 101st Airborne had reunions--in that case one can only imagine this band of brothers gathered to remember the trials, victories and losses experienced by the members of this group. Among them was Richard Winters, who most members of this group acknowledged as having offered something special to the group, although I'm not sure they would say he was in any way more valuable than the men he led, that he was any braver or more important when the fighting started. He did his job and they did their jobs. 

Tom Brady is arguably, more important and more valuable compared to the other members of his teams. He was essential, and other players were not. He may have even been more talented, although in many ways he could not match his teammates--he was not the fastest, nor the most intimidating, and everything he did depended on other people doing their jobs, while a wide receiver could simply run by the competition.

So, judging members of a group, even in retrospect, is dicey.

It is important to baseball players to be named to the Hall of Fame, even as they become old men--they want that honor. But then, in baseball, there are lots of records kept of accomplishments for every player who ever set foot on a major league diamond--except, of course, for the Negro League players.

There are between 500,000 to 1 million books published annually in the United States, not to mention songs written, and the Nobel Prize committee could not possibly read all of them, but they could look at Bob Dylan's work over the years and recognize a special talent, and understand the vast influence he had over his and succeeding generations. His pick was the obvious one. He really was the outstanding talent of his time in literature, or at least he was an outstanding talent.

But how do you judge outstanding graduates of a medical school?

I was surprised to learn that Cornell Medical College even had a "first in his class" designation. We were never told our grades and I was not really aware we were assigned grades. During the first two years, when we were confined to classrooms and everyone was taking the same classes and exams, it would have been easy enough to tally the highest scoring students. But, actually, remembering the questions on those exams--"Do fungi have chitin in their cell walls?" one has to ask: Who cares?

Those faculty in the "preclinical years" were astonishingly inept at their jobs. The faculty of Microbiology wanted you to know which bacteria were gram positive or gram negative, but it never occurred to them to discuss how different "gram negative sepsis" was from a gram positive pneumonia.  The course in Pathology had its moments, and one or two faculty who actually knew how to teach, and Physiology was the exception that proved the rule.

The faculty of Physiology actually knew how to teach, and actually had put in some thought about how to convey information and which information was important, worth learning and remembering. Of all those courses in the preclinical years, the concepts of physiology proved useful over the ensuing years and formed a basis for ongoing learning.

But the rest of those two years was a vast wasteland, taught by an ossified faculty incapable of decent teaching.

The emphasis was on isolated "facts" a high percentage of which proved wrong over ensuing years, but the concepts--the heart pumps blood to the brain--endure.

The one professor everyone agreed presented his material in a compelling way was Bean Kean, who taught tropical (parasitic) diseases, a sort of adjunct faculty member, a real showman, who took what could have been a course in extreme arcana an transformed it into a dazzling display of what everyone agreed was the best, most fun course of those years.

When it came to the third year of medical school, the clinical year, where you went on the wards every student experienced that year a little differently. There were rotations in Ob/Gyn, Medicine, Surgery, Pediatrics, Psychiatry and  Neurology, which were required of all students, and then there were electives in orthopedics, urology, and other specialties, and it was understood that most students would not care about certain courses--I had absolutely no interest in Pediatrics, although I later wished I had, once I had children to raise. 

My first and only intimation that the faculty had some idea of my own performance compared to others happened when one of the Deans, Fletcher McDowell, asked me what had happened to me between the 2nd and 3rd year of medical school. I had no idea what he was talking about. 

"During the first two years you were in the middle of the class, maybe just below the midline, but in the third year, you got honors in every subject except Surgery and Pediatrics. Fred Plum gave you honors in Neurology and that happens about once a century."

Some said the first two years showed how intelligent you were and the third year was all about charm and personality.

I did not buy that for a moment. My roommate used to study by propping up his feet on his desk and placing his book in his lap and just reading, no underlining, no jotting things down, just reading. Looking at him you could not tell if he was even awake. But when it came to knowing if fungi had chitin in their cell walls, he was your man. 

When we got to 3rd year Medicine, the resident on rounds stopped outside a patient's door and asked my roommate a question about anemia and he was totally at sea. Then the resident turned to me, and asked about the patient's anemia, and I had a complete outline of anemia in my head--there were the anemias of lack of production of red blood cells and the anemias of loss and destruction of red blood cells, and then I ran down the members of each class and why this patient had blood loss anemia, as was suggested by his positive stool guaiac. 

My roommate, humiliated, flabbergasted, asked me how I did that. I had always studies using outlines, concepts on which to hang important information, so I could recall and use it when faced with patients. He just memorized. So he was a star the first two years, but I could use what I knew. It wasn't a matter of charm. You could not charm your way past Fred Plum, Chief of Neurology.

And so, I had no chance of being first in my class, but why would I care? I learned what I thought was important. I wanted to be able to get patients through the night, alive.

Once we graduated and the diaspora commenced--most graduates left Cornell and headed out all across the country to do their internships and then dispersed yet again when they chose their specialties--I lost track of what happened to my classmates and what they might have accomplished and I had no reason to believe the medical school knew any more about their fates than I did. 

Discovers of Insulin U. Toronto

Sometimes, reading the "Class Notes" in the alumni magazine, I could see some had become faculty members in medical schools, and got prizes for studies of diabetic foot disease or whatever, and one or two became chairmen of departments at prestigious medical schools and written textbooks and articles. But was a chairman of a Department of Medicine more estimable than a local medical practitioner who saw his patients daily in the office and hospital, who met them in the Emergency Room and saw them through their crises? 

I suppose there might be some who had achieved "special achievements" but what could be more special than showing up to bail out a diabetic in ketoacidosis during the night?

Some, like Tony Fauci, 6 years ahead of me, did become rich and famous. But Fauci, for all his virtues, never discovered anything of great moment. He had a lab and would never have been heard from again, until he rose to administrative importance when HIV/AIDS hit. But he was never the moving force Cliff Lane, his colleague in the lab was, and it was not his lab which identified the HIV virus. Nor was it his work which made mRNA the platform for the vaccine that saved the world. 

Fauci was a man who believed he had got where he was by talent, hard work and perspicacity. And he surely had worked hard, but I suspect he lacked insight and the ability to think outside the box, although I'm just guessing about that. Of course, he did the nation a huge service by becoming the voice of reason during a dark time when Trump tried to deny science. Fauci deserved his fame and the adoration of the masses.

But who in our class of 1973 has become its Bob Dylan or its Katalin Kariko, who pursued the mRNA platform for vaccines (and got the Nobel Prize for it) despite being dismissed, fired and demeaned at the University of Pennsylvania?

Who in our class identified a virus like HIV or COVID?

Who in our class deciphered and unveiled the human genome?

Who in our class developed drugs which use the immune system to selectively attack various cancers?

At a recent meeting in Lawrence, Massachusetts I met a man who loudly bragged he was trained by C. Walton Lillehei, who had invented the heart lung machine and taught the men who did the first heart transplants. This man was a graduate of Cornell, 1974. 

And I thought, "Isn't the story of C. Walton Lillehei just the emblematic story of Cornell?" He was hired away from the University of Minnesota and arrived at Cornell like the second coming of the Messiah, but soon the recovery room nurses were saying his patients were too often being rushed back into surgery, or simply not getting off the table alive. 

Operating room nurses agreed--he may have invented the heart lung machine, but he was a surgical catastrophe. Somehow, what medical students were hearing from nurses in the cafeteria did not percolate up to the clinical faculty and people kept referring him patients. Ultimately, he was kicked out when he made the front pages of the New York Times and Daily News, because he had been charged with income tax evasion for writing off payments to Atlantic City prostitutes as "professional expenses."

There you have the true story of the Cornell hierarchy and its capacity to judge worth and value in its progeny and "family."