The Wait In The Emergency Department….

 

I just got back from the hospital.  My wife was admitted with acute appendicitis and is scheduled for an appendectomy in the morning. That sounds like a routine occurrence.  There are after all about a quarter of a million appendectomies done in the US every year.  I had a complicated case myself at age 18 with a perforated appendix, sepsis, and a weeklong stay in the hospital with a drain in my side. It was one of the sickest episodes in my life – even after the appendix was removed, I could barely talk with my friends who came to visit due to the pain and intense malaise – but mostly the malaise - an intense feeling like you have the flu but many times worse.

The problem started at about 2PM today when she noticed some nausea and abdominal pain.  She thought it started after drinking some coffee at her health club along with a protein drink.  Over the next hour she became intensely nauseated and started to get increasing pain.  She asked me to examine her and she had tenderness with some slight rebound tenderness in the right lower quadrant but no abdominal wall rigidity.  I suggested we go to the emergency department to get assessed for appendicitis.  She declined because she knew the process would take hours.  She preferred Urgent Care – but I reminded her it was the place of no urgent lab results and over penetrated x-rays.  There was nothing urgent about any of the Urgent Cares we had been to in our health plan.  I finally convinced her that the ED was the only place where things get done and I was worried that she had an acute abdomen that would only get worse. 

That is exactly what happened over the next two hours – increasing pain and nausea.  She was eventually vomiting continuously and in severe pain.  So, we headed down to the ED and got there at about 7:10 PM.  The check-in was excruciating slow.  An RN asked her about 50 questions while she could barely sit in the chair.  She kept saying that she had to lay down.  The nurse finally said – “I wish we had a bed to offer you but we don’t.  You can lay down over there on the waiting room chairs.”  The chair she referred to were in the triage area.  My wife laid across two normal sized chairs and covered herself with a blanket we brought from home.  We were interrupted by a nurse who took her down the hallway gave her medication for nausea (Zofran) and pain (hydromorphone).  She came back to those chairs but we were eventually asked to go to the general waiting area.  I took this picture of her laying across a larger bench style chair that was too short for her to lay flat.  The blanket is our own.

By 3 hours she was finally given a bed in the ED low acuity area and more Zofran and hydromorphone.  That stopped working a lot sooner.  She was sent for a CT scan of the abdomen at the 3 ½ hour mark.  That was preceded by a visit by an ED resident and later the attending physician. We got the final CT result about 1 ½ hours later when I went out to report she was continuing to get worse and the medications did not seem to be doing anything.  The Zofran was changed to Compazine and more hydromorphone was given.  Eventually a new ED physician came in and explained that surgeons had been called and that an appendectomy would probably be recommended.

At that point it was after midnight and I discussed me going home after I had said my piece with the surgeons.  I had two specific concerns about antibiotic coverage.  My wife was out of it by then but whispered: “Just behave yourself.”  When you have been married as long as we have - that snappy repartee develops.

On the long drive home, I had time to reflect on a number of things.  First, I was an intern at this hospital in 1982 and at that time we had a trauma wing and a non-acute wing.  Interns would rotate from one side to the other every other night.  The attendings on each side wanted to get people in and out as quickly as possible and they emphasized that point to us.  There were no bottlenecks and people were triaged based on acuity.  There was a sign there tonight saying that was still the rule.  Of the 30 or so people in the ED waiting room are, there was possibly 2 other people as ill as she was.  They were all laying on waiting room chairs.  Second, the pace was leisurely with a lot of down time. I still don’t understand why it takes 6 hours to get a diagnosis of acute appendicitis when I could do it as an intern in 15 or 20 minutes without a CT scan (we were told the CT scan results took 30 minutes to get back.)  Third, if EDs are that inefficient why not offload some of the front-end work to Urgent Cares.  That would entail making an Urgent Care urgent – a place where you can get a rapid assessment and the necessary tests and (hopefully) get directly admitted to a hospital and treated.  Fourth, the bottleneck suggests to me that beds are being rationed at some point.  We were in the second busiest ED in the Twin Cities. At some point – ED demand has been well defined and it should be accommodated.  Fifth, the place is run down. When I was there the argument could be made that it was worse, but this is a brand-new addition to the front of a brand-new addition to an old hospital.  It had the gestalt of a bus depot. People were milling about coughing and sneezing around the people laying on chairs waiting to get a bed.  Not a good look for either patient satisfaction or infection control.

All things considered it is an ongoing suboptimal experience. Nausea and pain were tolerated far too long with little follow up on the initial results.  It highlighted to me the need for an advocate when you go into a hospital these days – not just to prevent major problems but also to troubleshoot around routine decisions like: “Should I press this call light because not only does the medicine not seem to be working but I feel a lot worse.” Or “Maybe you should ask that doctor again if they have the CT results – it has been an hour.”   And of course, if you know additional history as an advocate that is valuable information.

Were there bright spots?  Both the ED and surgical residents had a great interpersonal style.  They gathered all the relevant information, were personable, and the surgery resident did a great job with the informed consent for the surgery. That’s about it.  It took 5 hours to get to the two physicians who could do something and then another hour to do it.  I told the surgeon I was in the same ED as an intern and then went into psychiatry.  She said that her experience on psychiatry was “heartbreaking” and she thanked me for my service.  Not the first time that has happened.

That is all I know at this point other than the fact that my heart rate was up the entire time I was part of this process – probably by 30 or 40 beats per minute.  I got home at about 1:45 AM and got about 4 hours of sleep.  A call to her nurse this morning for an update resulted in me finding out that she is still in the ED at 9 AM.  She is now getting IV fluids, antibiotics, anti-nausea medication, and pain medication. Her surgery is not scheduled until 3:45 PM today.  The nurse reassures me that she will be in a hospital bed after the surgery and may be able to go home the same day.

This is state of the art health care in the US.  After 40 years of micromanaged health care by managed care organizations we have a system that is less efficient and patient centered than the one I was trained in back in the 1980s. The only real innovation has been the use of CT scanning for the diagnosis and that was scientific innovation rather than business management.  Despite all the patient satisfaction surveys we have a system that no patient should be satisfied with.

 

George Dawson, MD, DFAPA 

Update 1:  My wife had surgery today approximately 23 hours after presenting to the emergency department with acute abdominal pain.  It occurred at about 6:15 PM.  I have highlighted what happened over the first 24 hours in the timeline below. I have not filled in the medications yet – but she was taking an anti-nausea medication (Zofran or compazine) and pain medication typically hydromorphone or oxycodone.  She was getting IV fluids at a rate of 50 ml/hour and at one point became hypotensive and the rate was increased. 

The surgeon discussed the results of the surgery with me. The appendix had perforated and as a result they had to clean the area to clear away that debris.  The procedure was maintained as a laparoscopic appendectomy despite the area of infection.  The surgeon quoted a 20% abscess formation rate with this complication.  We discussed the importance of the right antibiotic combination to prevent infection and secondary infection of a recent hip arthroplasty.  The surgeon emphasized that despite previous statement – my wife would not be going home because she continued to need IV antibiotics and oral antibiotics at the time of discharge.  When I left the hospital, my wife was alert and had some continued nausea and abdominal pain.  She was in good spirts and the nurses were discussing how she would start the night out with frequent monitoring and how that would taper off into the next day.

The issue of antibiotic coverage for a hip or knee arthroplasty is somewhat controversial in terms of antibiotic coverage. Most sources suggest a first- or second-generation cephalosporin and metronidazole.  I will put the medications on the timeline if I can convince the nurses to print out a copy of the MAR (Medication Administration Record). Hoping that discharge is imminent if there are no complications tonight.

 The antibiotic issue in appendicitis is also controversial.  There is a debate about just how good a purely medical/antibiotic approach to appendicitis is.  For example, there is a high recurrence rate of symptoms after treatment with just antibiotics.  There is some uncertainty about whether the risk for perforation is reduced and there is currently a protocol to study that problem.  It seems fairly straightforward if you consider that a partial mechanism is that the infection causes circulatory compromise and this leads to tissue damage including necrosis and leakage of the appendix contents.  The CT imaging may also be predictive.  The first surgery resident suggested that if a pattern of obstruction was visible there would more likely be perforation and disseminated infection.  My wife’s CT scan had that pattern and she did sustain a perforation.       

Update 2:  My wife was discharged today (11/15/2024).  Nobody explained the rationale – but I am speculating it was because her blood pressure stabilized (she was hypotensive), she did not have a fever, and her physicians thought the current level of pain and nausea that she has will resolve in the next week.  She was discharged with 4 doses of a cephalosporin and 4 doses of metronidazole after receiving an undetermined amount of antibiotic.  I say undetermined because she requested a printout of the medications administered (MAR) and were told they would not give it to us.  Instead, we should go down to medical records and sign a release to get this printout.  That made no sense to me but I have encountered this resistance at this hospital before that included having to pay for a third party to send me many irrelevant records from my own treatment.  I would think that the world’s most expensive electronic health record would have no difficulty with this task.  We were given an incomplete discharge instruction sheet instead that highlighted some of the problems with this EHR – not the least of which is reconciling the discharge medications.

We were told that follow up will be with my wife’s primary care physician.  No mention of the 20% chance of an intrabdominal abscess or what to do about that.  Just instructions on how to inspect and care for the laparoscopy incisions. My wife also has a 6-week-old arthroplasty of the right hip. I emphasized the need for antibiotic prophylaxis to prevent infection of that hip to the surgical team.  Her orthopedic surgeons advised her not to get any dental work done for 6 months (it is 80% healed at 3 months) and in terms of bacterial exposure a perforated appendix is probably as problematic as dental work.  I will need to confirm with orthopedics about whether a longer course of antibiotics is needed.

She is currently ambulatory, in good spirits, and has pain, and nausea.  No nausea medications were given on discharge. A limited amount of oxycodone was given for pain at half the dose she was taking in the hospital (10 mg). The bulk of the pain treatment was a combination of ibuprofen, acetaminophen, and methocarbamol.  This polypharmacy approach to postop pain seems common these days.  I will be assisting her with the medications and helping her monitor her condition.  I will also be researching the antibiotic issue and trying to get in touch with her orthopedics team.

Supplementary - more on malaise - I use the term frequently on this blog and often interchangeably with "flu-like illness".  It probably correlates with systemic inflammatory components released during infection like cytokines.  Watching my wife go through this course of appendicitis - I was reminded of what I went through 50 years ago.  At that time I became acutely ill in a period of hours, met my primary care physician in the ED, and he took my appendix out and placed a drain in my side in a period of 2 hours.  I was in the hospital for the next week.  I can recall an intense sick feeling that was not associated with pain or nausea.  It was so intense - it was the only time in my life that I did not care if I lived or died.  I just wanted it to stop.  Friends visited and I could barely talk with them.  This is my understanding of malaise at the severest level.     

Flashbacks on Election Night...

 

Well – the 2024 election is over and I thought I would bring it to a close with this final post on the issue.  As previously stated, I am a small “I” independent and have never registered as a Democrat or a Republican.  Except for Barack Obama and Joe Biden - I have voted for Ralph Nader in nearly every other Presidential election that I have voted in.  As you can see from recent posts, I absolutely did not want Trump or his minions anywhere near the White House again.  It is astounding that it has happened.  To make sense of it – sometime last night the media started to spin it as Trump being some kind of genius or popular hero.  That lacks any real explanatory power. The media has done an incredible job during this election making Trump seem to be a normal Presidential candidate when he is far from it. It was quite a spectacle this morning watching the morning TV gang falling all over themselves making this seem like a miracle – when they essentially staged it.

You do not have to be a psychiatrist to see the obvious problems here but apparently it helps. I have listened to Trump voters interviewed and during those interviews they can provide no rationale for their vote.   I have listened to young voters interviewed and it was not clear that they knew anything about how voting works in the United States.  Young voters are criticized for being ideologically self-centered as if older voters are not.  The only voters that made sense were self-identified Republicans who could not vote for Trump based on his attempt to overthrow the elected government of the United States.  You would think that would be a hard stop for any law-abiding citizen.  Back in the day when I took civics, I think it was referred to as treason.  Beyond that small problem, nobody seems to recall all of the other the legal problems that would keep the average person from getting an interview just a few years ago.  Somebody posted that Americans need to stop pretending that they are superior to everyone else when they put a guy like Trump in the White House.  Trump could not get a job at Piggly Wiggly and he is now President of the United States.  That personifies everything that is currently wrong with the United States.

There has been no discussion of the rhetoric used in this campaign particularly Trump's.  To cite one example, in a previous post about the initial debate with Biden - Trump suggested Biden had “destroyed” the country (he used the word destroy 22 times) and he is the “worst” President – (he used the word worst 22 times). All that despite the fact that Trump produced no useful content on policy and did not respond to Biden's comment that in a scholarly ranking of presidential achievement - Trump was dead last (Biden was 14 out of 45 and that has probably improved).  This has been Trump's strategy in every speech.  No content and irrational personal attacks.  He attacked Harris' ethnicity and called her a "bitch" several times (2-4) as well as many other derogatory names and insults.  And there was no criticism of this by anyone apart from Biden in the debate, who was characterized instead as old and feeble by the press.

Of course, Trump opponents are also issuing conciliatory statements acknowledging the win and wishing him the best.  They are doing everything he would not do and ignoring all his vicious name calling along the way. I have not heard the usual platitudes about how he is the President for all Americans yet – but it will be coming.  Let’s face it – he is not the President for all Americans.  He is the President for the powerful and the gullible.  OK - I will acknowledge that maybe there are still a few loyal Republicans caught in the headlights who don't realize the party of Reagan has been transformed into a cult. 

He was described as a transactional President by the BBC today (3).  In other words what does he get out of what he gives in negotiations?  It came up in a conversation with a Ukrainian Prime Minister Kira Rudik reminding everyone that Trump said he would solve the war in Ukraine in one day.  And later that he would solve the war in Ukraine before he was in office.  Those are the first of many failures that I will be looking for and pointing out.  Trump is completely disingenuous and I expect to see a long list of failures.

One major point that seems to be missed about this election outcome is that it is a textbook example of how rhetoric alone can carry the day – even when there is a complete lack of substance.  This is a critical point that I have not seen analyzed by anyone. If anything – the press is still reacting to Trump’s rhetoric as though it is true. The economy is a clear example.  Trump has described it as a disastrous failed economy due to Biden and Harris. The press still accepts that despite the recent edition of the Economist pointing out it is an outstanding economy as far as economies go.  There is the other reality piece that Presidents don’t have that much of an effect on the economy anyway – but the economy persists as a top explanation why Trump won.  It really wasn’t the economy – it was false rhetorical ideas about the economy. 

The second most common narrative to explain the results is that Trump sold himself to the commoners as someone who would attack the “elites” and either burn the system down or take them all down a notch. I heard Mark Cuban on Sam Harris’s podcast describing the elites as basically anyone Trump wanted to criticize – generals, doctors, etc. So the elites are basically the rhetorical targets of Trump. They don’t really meet any unique definition of elites.  And the definition of elites is quite wide ranging from people with special abilities to the wealthy class. Is a general concerned about Trump’s treatment of military veterans and war casualties an elitist?  What about the billionaires all circling around Trump and Trump himself?  What about the richest man in the world giving over $100M and intensive media coverage on his social media site to the Trump campaign and other MAGA candidates?  What about people who are clearly above the law compared with the rest of us? Any application of the elitist explanation must leave out the fact that Trump is one of the biggest elites of them all.   

The failure to see Trump as the character and intellectual failure that he is seems matched by rationalizations that equate him to your eccentric old uncle who shows up once a year at the family gatherings.  During the past months where his style was equated to autocracy (which it is) and Naziism (which it is not) – several excuse makers came out and said that Trump could not possibly be a Nazi because he is only interested in himself and not promoting any long-lasting ideology. So, if he moves on the dark cloud will go with him.  In another case, the Wall Street Journal stated: 

“We don't buy the fascism fears, and we doubt Democrats really do either. Our own concern is whether he can successfully address the country's urgent problems. Most second presidential terms are disappointing, or worse, and Mr. Trump hasn't mapped out a clear agenda beyond controlling the border and unleashing U.S. energy production.”

And

“The authoritarian rule that Democrats and the press predicted never appeared. Mr. Trump was too undisciplined, and his attention span too short, to stay on one message much less stage a coup. America's checks and balances held, and Democrats benefited from the political backlash.”

Yes – they really are suggesting that we can rest reassured that their candidate's cognitive limitations and complete lack of an agenda should be reassuring that he can sit in the White House and not try to fashion an autocracy with staying power when he has a raft of Mini-Mes at his disposal.  He has after all demolished the Party of Lincoln to the point where it is no longer recognizable as a legitimate political party and rendered it into a cult.

The other problem with all of this is that there is an expectation somewhere that all Americans will accept this atrocious set of affairs, reconcile with the people who voted for this man, and we will all be one big happy family.  That is very unlikely to happen.  What is likely to happens is that Trump and his cronies are likely to “double down” on all their intrusions into private life, functional government, and public safety.  Even today we are hearing about how Kennedy wants to eliminate FDA departments and Musk wants to impose a new austerity standard on all Americans. The Rolling Stone quoted several proponents of Project 2025 saying that they no longer must pretend that there is distance from Trump and they can now own the connection.  All of that translates to direct harm to the people who voted for Trump thinking that he is somehow interested in them.

There needs to be resistance to this at every level.  When the harm occurs it needs to be documented whether that is maternal mortality because some politician thinks they know how to manage pregnancy or increased infant mortality due to vaccination limitations or worsening asthma as a direct result of lax air quality standards.  I think that violence, gun violence, and violent crime will increase just because it is part of the MAGA culture.  Their standard response that they are the law-and-order party no longer applies – because they are not.  There is a long list that I will record over time.  Expect a PowerPoint.

As all of this was churning in my brain last night – I realized that Trump getting elected was just like me working on my acute care unit just before I quit.  I was lying in bed wide awake and feeling like an electric current was running through my body. It was impossible to relax.  My heart rate was elevated. It reminded me of why I can never go back to that kind of work again. Although I did it for 22 years, at the end it was intolerable.  I did not mind when the stress was due to trying to help people resolve severe psychiatric problems.  It was very problematic when the environment became politicized and I was one of the targets.  It also reminded me of the current danger, a dangerous man, and a dangerous party and why it is more important to be loyal and true to the idea of a country than a candidate.  Stay vigilant and don’t let this extremely bad turn of events get you down.

In the most basic final analysis – a vote for Trump was a vote for lawlessness, resentment, dishonesty, greed, corruption, and disrespect. It was a vote for big business managers and CEOs, misinformation, income inequality, climate change, pollution, government intrusion in your personal health care, and autocrats worldwide. 

How can that possibly end well?  

 

George Dawson, MD, DFAPA

References:

1:  Bensinger K, Yourish K, Gold, M.  Failing to Provoke Harris, Trump Turns to Tried and True: Vulgarity.  New York Times.  August 31, 2024.  https://www.nytimes.com/2024/08/29/us/politics/trump-crass-imagery.html

2:  Haberman M, Swan J.  Inside the Worst Three Weeks of Donald Trump’s 2024 Campaign.  New York Times.  August 10, 2024.  https://www.nytimes.com/2024/08/10/us/politics/trump-campaign-election.html

3:  BBC News Hour November 6, 2024:  Interview of Ukrainian PM Kira Rudik (starts at 19 min 27 second mark): https://www.bbc.co.uk/sounds/play/w172zb96nbcppzq

4:  Lu C.  Trump Wields Sexist Insults at Final Campaign Rally. The Republican nominee has a long history of misogynistic rhetoric.  Foreign Policy November 5, 2024.  https://foreignpolicy.com/2024/11/05/trump-sexist-insults-remarks-pelosi-harris-gender/

And all of the post-election spin claims Trump is not a misogynist.

Graphics Credit:  Thanks to Tyler Black @tylerblack32 for allowing me the use of one of his election graphics from X(formerly Twitter).   See the entire sequence for his statistical commentary on the election dynamics. 

Current Political Violence In The USA

 

One last political post before the election.  I have been working on a graphic on the political violence scenario and how it has drastically changed in the past 8 years. Part of the issue with aggression and violence is that it is generally very difficult for most people to talk about. They lack the vocabulary and for a long time there was the suggestion that it may have been the fault of the victim.  It took far too long to recognize that this was a dynamic in domestic violence situations and modernize those laws to set limits on the violence and ultimately prevent homicides. Another factor that recently came to light was the issue of firearm access by perpetrators of domestic violence. A recent court case challenged the ban on firearms possession by these men and contrary to the general trend of increasing gun extremism that ban was upheld (United States v. Rahimi).

I do not intend to elaborate on what is contained in the table. I encourage any reader to do your own research on what I have posted.  I have extensive references, but with these political posts – most people do not seem to be interested, especially when they run counter to the conventional wisdom or prevailing political rhetoric. Instead I will make some general comments on aggression, violence, and its effects.

As an acute care psychiatrist, I was faced with the problem on a daily basis.  Aggressive and violent people brought to my care generally by the police or paramedics.  The people I saw were involved in fights, shootouts, violent confrontations with the police, homicides (real and attempted), vandalism, threatening behavior, and suicide attempts.  The behaviors were extreme enough to precipitate 911 calls and for emergency responders to bring them to my hospital.  Not all hospitals take these calls because not all hospitals are set up to deal with violence and aggression.  The staff and the physicians need to approach it as a treatable problem.  That is the first lesson. Violence and aggression – even when it is caused by psychiatric illness is not considered a medical problem.  It is considered a moral problem.  In other words – the person intended to commit violent acts because they are either morally deficient or simply have no moral code. The vast majority of people I treated in this situation had a severe psychiatric disorder and did not know what they were doing. They could not appreciate the wrongfulness of their act.

In order for the person with aggression to be admitted to my unit – they had to have a psychiatric diagnosis rather than just criminal behavior.  That is an imperfect triage criterion and in a few cases, people were admitted with either criminal behavior or aggressive behavior that was goal directed to get what they want. Common examples include intimidating people for money or sex or just disagreeing with them. The associated excuses would be: “Well he/she had it coming.”, “They were just there when I went off.”, or "They did not give me what I wanted.”  These are all attitudes that people use who see others as strictly a means to an end. Other people are just there to be manipulated to get what they want. They are not seen as people just struggling along like everyone else with important goals and relationships. Resentment is a common theme and many of the perpetrators see themselves as getting a bad deal in life, not getting what other people have, and that may include loyalty in relationships.

All of that is a backdrop to the actual aggression or violence.  No matter how egregious that violence and aggression is – it is very common to see it minimized after the fact. That minimization can take the form of complete denial “I wasn’t there” to partial denial “I did not mean to kill him.”

On the less obvious end – aggression can include threatening behavior that involves appearing to be very angry and using profanity in someone’s presence for no clear reason, throwing objects, destroying property, right up to specific threats to kill or injure a person.  There is some confusion over how well these behaviors predict actual violent acts that result in injury but there are two considerations.  The argument has been made that psychiatrists really can not predict violence very well and that may be true for routine evaluations of relatively stable people in outpatient setting.  The prevalence of violence in that population is so low that I would not anticipate being able to predict it.  That changes in an acute care setting where the transition from verbal aggression or aggression toward property to physical violence against people happens very quickly.  The goal is always to stop it before the physical phase.

 At the societal level, the laws have slowly been changing to catch up.  Domestic violence laws lagged for decades until many states adopted the law that if a call occurred, an arrest had to be made. The law about domestic violence convictions leading to no gun possession was a similar development.  Finally, terroristic threat laws made it illegal to threaten people before any physical violence occurred. These terroristic threats laws have developed over the past 30 years and are really a major development compared with the idea that the person making the threats hasn’t done anything yet and we can’t do anything unless they do something.  It is hard to imagine how many people were directly threatened and heard that response from law enforcement.

The driving force behind these legal changes was recognition of what the victims were going through. In some cases, years of harassment, needing to take extraordinary measures to assure their safety, and suffering the effects of this extreme stress in the form of chronic insomnia, anxiety, panic attacks, post-traumatic stress disorder, depression, and physical symptoms.  In many cases jobs and families were disrupted.

The groups I named in the above graphic have been through all of that and more.  In the Insurrection there were estimates of 140-170 officers injured and 5 dead – one from injuries sustained at the scene and 4 subsequently by suicide.  I have not seen any specific reports of the number of police affected by mental health symptoms but expect it is significant. Various efforts have been made to minimize the event and the media seems to go along with them. Even though the popular press does say that one party and one candidate has been lying continuously that the 2020 election had been “stolen” – very little is done on a day-by-day basis to confront this lie.   Nobody is saying that we have a Presidential candidate who attempted to overthrow the elected government of the United States and currently has operatives in place to disrupt the current election. That may be why 1 out of 3 election workers report being harassed often to the point that they quit volunteer jobs that they have been in for decades. 

The remaining groups in the table are self-evident.  We have all seen people screaming and threatening in school board town hall meetings.  There are substantiated reports of severe threats to public health officials and disaster workers. This is all politically motivated aggression and violence that is precipitated by misinformation and political rhetoric. A good recent example was the attempt to connect anti-immigrant rhetoric to hurricane relief and suggest that funds were being diverted to undocumented immigrants. Gun extremism and abortion clinic violence predates the most recent cycle but are good examples of the process. Make emotional inaccurate claims, blame somebody for the problem even if they are law abiding, and let the chips fall where they may.  This process just keeps repeating itself with a party that always doubles down, never acknowledges they are wrong, and never acknowledges what they are really doing – dividing people and turning them against one another.   This line of rhetoric also distracts from the fact that the party in question really has no acceptable policy.  When their self-proclaimed genius economic policy was vetted by Nobel laureates in economics it was found to be seriously deficient.

When I posted this graphic on another site I was immediately confronted with the question about violence and crime created by undocumented immigrants.  I responded with a study done by the Department of Justice based on the arrest records of the most right wing state in the US – Texas. That study shows that these people are much less likely to be arrested for violent or property crimes than citizens born in the US.  Even without knowing about it – it makes sense. The people at the southern border are fleeing corrupt governments and criminals in South and Central America.  The last thing they want to see happen is to be deported back to their country of origin. Because they are undocumented, they need to maintain as low a profile as possible. That would include no encounters with law enforcement.

The idea that political violence could be compared to violence by undocumented immigrants is a feature of the rhetoric used to obscure the real problem. That real problem is that there should be no political violence at all in the United States.  Politics in this country is supposed to operate on the peaceful transfer of power and no party using its power to intimidate either the voters or the election process. We are way past that at this point and it is all on one party.  The political violence is a direct effect of dishonesty and manipulation.  There has not been an adequate effort by the opposition to push back in many of these areas and that leads me to have grave concerns about the upcoming election.

I am hoping that the vote rejects political violence and all that involves so that people can feel safe and we can start to focus on real problems instead of contrived political problems.  You can get rid of political violence by voting it out - at least in this election.  It will be a worse problem to get rid of if it becomes institutionalized.

 

George Dawson, MD, DFAPA

Supplementary 1:  Unfortunately I have to keep adding boxes.  The latest is a direct comment form former President Trump.  Before anyone suggests he was just "joking" or "nobody takes him seriously" or tires to explain it in any other way consider this.  This is unprecedented discourse in an American election.  It follows Trump threatening to use the military against his perceived "enemies form within."  It should be fairly clear that he considers political opponents or in many cases people who just disagree with him as enemies.  Violent rhetoric aside - this is not an attitude any reasonable politician can have when they are supposed to represent all of the American people.

Why A Diagnosis Is Not Stigmatizing and What Is...

 

 

The topic came up last week and it happens on a recurrent basis – diagnoses especially psychiatric diagnoses are not good because they are stigmatizing.  I addressed this fairly comprehensively in a post on this blog 10 years ago, but the persistent antipsychiatry rhetoric out there keeps repeating inaccuracies.  Since then there has been a comprehensive academic definition of stigma that makes things clearer.

Before that academic definition the standard dictionary definition was “a stain or reproach, as on one’s reputation” (1).  There is also a medical definition that is used to designate obvious pathognomonic findings: “visible evidence of disease” (2) and a long list of signs that apply.  There are additional definitions that do not apply to the specific situation of how mental illness is stigmatizing. The American Psychiatric Association has a web page on stigma and the adverse effects.  The web page does a good job of breaking it down to the public, personal, and structural levels.  Specific evidence-based interventions are suggested. They typically involve first-hand experience of persons with mental illnesses.

More sophisticated definitions of stigma are available today.  For the purpose of this post I am using one by Andersen, et al (3) that modifies previous work done by Link and Phelan (4).  According to the authors, stigma is a social process that involves “labelling, negative stereotyping, separation, and power asymmetry.” (p. 852).  They state further that stigma is not present unless all these criteria are met – specifically stigma exists “if and only if” all these criteria are present. 

Labelling in this case is defined as “social selection of human differences”.  The authors give an example of associating alcohol use with homelessness and whether it is a matter of “cognitive efficiency” based on personal experience and probabilities. The labelling that occurs is a result of these socially observed differences. Although these labelled associations can be positive, for the definition of stigma only negative associations are relevant for stigma.  That results in the negative stereotyping.

Separation creates a false barrier between the negatively stereotyped and everyone else.   It suggests that there cannot possibly be any overlap between the characteristics of the stereotyped and everyone else.  Earlier in their paper, the authors use the example of obesity, where it is obvious that there are several almost universal stereotypical qualities and overt discrimination. The same thing is true of ageism, where it is often assumed that elderly people are universally frail, cognitively impaired, and have negative personality traits. It is an us versus them mentality that is currently popular in right wing politics in the US.

Power asymmetry is attributed to the fact that is takes social, economic, and political power to label and negatively stereotype. This is inconsistent with the idea that it happens at an individual level and those individuals together can form a power structure. 

The authors cite an example from Link and Phelan: “They notice that mentally ill patients might label clinicians as e.g. “pill pushers” and link them to the stereotypes of being cold, paternalistic, and arrogant. But the clinicians will not, therefore, be a stigmatized group, because this group of patients simply do not possess the sufficient power to “(…) imbue their cognitions about staff with serious discriminatory consequences.”   

The social and pollical dimensions of the pill pusher characterization ignores history and the prevalence factor.  On a historical basis, Osler suggested that medications being used over a century ago were either worthless or cause more harm than good.  At the turn of the century "dope doctors" ran large practices by keeping people addicted to opiates. On the prevalence side, does the number of people with that characterization equal or exceed the number of people with other common important stigmatizing biases like obesity or ageism?  I doubt it. We do see an excessive amount of rhetoric directed at psychiatrists that is largely inaccurate and contrived and it is not without professional, social, and pollical fallout (5,6).  Very few reasonable people seem willing to discuss that.  The other reality that is rarely discussed is the fact that doctors are not powerful and certainly are not trained to use or exert power.  Today they are ordered around by middle level managers with no training in medicine exerting whatever form of administrative power that they choose.

There are much better examples of stigmatizing processes that are obvious but never discussed in today’s world.  I come back to the entertainment industry at the top of the list.  Apart from movie reviews psychiatrists have been curiously silent about this process that has gone on unabated for decades.  To cite a recent obvious example, I would refer anyone to the most recent episode of The Penguin an HBO series.  In season 1 Episode 4, we see one of the protagonists falsely diagnosed with mental illness to keep her from disclosing several homicides committed by her father.  She is placed in a medieval Arkham asylum where the patients are shackled by the neck and treated inhumanely.  She is eventually baited into committing a very violent homicide against another patient who is trying to befriend her.  The psychiatrists there are portrayed as indifferent at best and of course using electroconvulsive therapy as a punishment (there has not been any progress on that issue since One Flew Over the Cuckoo’s nest in 1975).  There may be people who argue these problems may have existed in 18^th and 19^th century asylums – but the problem is this is set in modern times.  The Penguin is driving a 2013 Maserati Quattroporte VI.  This episode plays the familiar stigma as the mentally ill being excessively violent and psychiatrists as agents of the state conspiring against people, using psychiatric treatments as punishments, and not caring at all about individual patients.

Right wing politics is a second source of stigmatization on almost a daily basis.  Trump and affiliated MAGA politicians routinely suggest that mass shooting and gun violence are attributable to mental illness – even though it clearly correlates with firearm availability and density.  In the case of undocumented immigrants, they are triply stigmatized as criminals, mentally ill, and invaders of the country when there is no evidence for it.

A final source is a carry over from my previous post.  Businesses and healthcare companies actively discriminate against mental illness despite parity legislation.  That should be obvious by the lack of resources that people face when trying to find treatment for a severe mental illness. It is easy to find state-of-the-art care and subspeciality care for any other bodily symptom – but not psychiatric care.  Getting an appointment to see a psychiatrist even in large metropolitan areas is often impossible.  Inpatient bed capacity in the United States is somewhere below the bed capacity of developing countries in the world. The majority of people with mental illnesses are not treated.

That is my update on stigma.  The only thing that has changed in the last 10 years is the current spin that a psychiatric diagnosis or treatment is stigma or stigmatizing and of course it is not at all.  As a reminder, a diagnosis is for the information of the patient and other treating professionals, it is confidential, and it is used by people who are professionally obligated to act in the best interest of the patient and incorporate that person's preferences.       

 

George Dawson, MD, DFAPA

 

1:  Random House.  Webster’s College Dictionary.  Random House, New York, 1996: p. 1314.

2:   Steadman’s Medical Dictionary.  The Williams and Wilkins Company, Baltimore1976: p.1338

3:  Andersen MM, Varga S, Folker AP. On the definition of stigma. J Eval Clin Pract. 2022 Oct;28(5):847-853. doi: 10.1111/jep.13684. Epub 2022 Apr 23. PMID: 35462457; PMCID: PMC9790447.

4:  Link BG, Phelan JC. Conceptualizing stigma. Annu Rev Sociol. 2001; 27(1):363‐385.

5:  Perlis RH, Jones DS. High-Impact Medical Journals Reflect Negative Sentiment Toward Psychiatry. NEJM AI. 2023 Dec 11;1(1):AIcs2300066.

6:  Bithell C. Why psychiatry should engage with the media. Advances in psychiatric treatment. 2011 Mar;17(2):82-4.

Photo Credit:

Click on photo to see Wikimedia Commons information about photo and photographer as well as CC license.

American Democracy is at Best A Semi-Rational Process

 

“Political language … is designed to make lies sound truthful and murder respectable, and to give an appearance of solidity to pure wind.”  George Orwell in Politics and the English Language, 1946.

 

In the closing month of the federal election for President, I think it is useful to consider my previous comments on the Goldwater Rule and Does the Insurrection End The Debate on the Goldwater Rule.  The rule was promulgated by the American Psychiatric Association to prevent casual comments about psychiatric diagnoses of candidates when they had not been examined and given permission for those diagnostic evaluations.

I have always been in favor of this rule largely because it is outside the scope of psychiatric practice and like many forensic settings there can be a prominent conflict of interest based on political affiliations.  It also turns the diagnostic process on its head in that it is no longer used for the benefit of the patient, but the benefit or lack of benefit falls to third parties.  And finally, whenever psychiatric diagnosis is used in the press or other forms of common usage they lose their real meaning. They are no longer useful observations but, in many cases, become ad hominem attacks.

I have not counted the number of comments about narcissistic personality disorder, but it has grown significantly since the 2020 Presidential election and several commentaries that Trump had that disorder.  Antisocial personality disorder and psychopathy (a trait rather than a formal disorder) have also been used to describe him.  Since the terms became more visible, they have been widely applied.  You Tube and TikTok videos suggest how to make the diagnosis yourself or at least recognize it.  They describe typical speech patterns and how you should respond.  Many describe the red flags.  After watching this material none of it seems useful to a psychiatrist who makes the diagnosis and provides treatment. 

There seems to be a significant overlap with people who are difficult to get along with – often in asymmetrical roles like employer-employee.  Do the conflicts that typically happen in these situations rise to the level of a psychiatric diagnosis?  Do conflicts and misunderstanding that occur in other interpersonal relationships rise to that level? Probably not.  But there is a whole lot of videos encouraging people to make that diagnosis.   

The original arguments for making a psychiatric diagnosis on former President Trump were basically threefold.  First, that it was a professional obligation.  Psychiatrists were obliged to warn the American people about the dangers of any diagnosis basically as a public service.  There are several problems with that approach – the most significant being that diagnoses are associated with a wide range of behavior of varying severity and not predictive of anything specific.  It is unlikely that any diagnosis would have predicted the wide variety of significant problems that Trump exhibited following the election. The other problem of course is that it removes the Constitutional threshold for action by the Cabinet and replaces it with a much lower threshold – the psychiatric diagnosis.  It is basically the reason why people do not undergo civil commitment or guardianship proceedings based on a diagnosis.  The law requires obvious behavior that can be observed by any lay person. The 25^th Amendment standard is “ a written declaration that the President is unable to discharge the powers and duties of his office” from either the President himself or a “majority of either the principal officers of the executive department or of such other body as Congress…”  The determination is strictly based on lay observation and not medical or psychiatric evaluations.  Second that it provided additional information for voters that they could use in making their decision.  And finally, the somewhat grandiose assumption that it may be a superior method than the judgment of officials mentioned in the 25^th Amendment. All of those assumptions have failed at multiple levels.

Rather than be concerned about Trump’s diagnosis this may be a question of voter capacity or competence.  In other words, is the voter using available information to make a rational choice?  And can the available information be analyzed rationally?  That requires more than just stating a preference.  It requires a rationale for casting the vote. This is also a difficult measure because there is a value system baked in to some of these decisions.  For example, some votes are based on single issues or traditions like always voting for members of a certain party. Some votes are based on issues like abortion, guns, and censorship even when it is clear the results have been worsening medical care for women, gun extremism, and book banning that includes shutting down some school libraries. The value system can also include extremism like guns, racism and antisemitism.  Even though most reasonable people would agree those values have no place in modern society – they do not disqualify people who value those ideas and vote on that basis.  All of this illustrates why voting is a semi-rational process. On that basis you can also ignore all the negatives that members of the same party or Cabinet say about a candidate’s intellect and character.

The only inconsistency in the law that occurs is that capacity to vote is considered in guardianship and conservatorship decisions by the court.  In my experience I have seen the county forms, but in the hundreds of assessments that I have done – capacity or competency to vote was never a dimension that I commented on.  Associated capacities for entering marriage and contracts were also typically listed but not commented on.  In practice it may be that people who are under guardianship or conservatorship are not offered a trip to the polls or a contract but I cannot say for sure.

The polls themselves handle the issue like everything else in the law and politics as a contentious issue.  For example, these are direct quotes from Minnesota Statutes regarding election procedures:

“Mental capacity is a question of fact for judges of election.” Op. 82, Atty. Gen. Rep. 1942, October 22, 1942.  p. 26

and

“Provision of Minnesota Constitution prohibiting a person under guardianship from voting at any election in the state did not violate the Equal Protection

Clauses of the U.S. and Minnesota Constitutions, since pursuant to Minnesota statute, persons under guardianship were presumed to retain the right to vote, and the constitutional prohibition against voting based on guardianship status applied only when there had been an individualized judicial finding of incapacity to vote. Minnesota Voters Alliance v. Ritchie, 890 F. Supp.2d 1106 (D. Minn. 2012).”  p. 43

The county auditor shall mail a notice indicating the person's name, address, precinct, and polling place to any registered voter whose civil rights have been restored after a felony conviction; who has been removed from under a guardianship of the person under which the person did not retain the right to vote; or who has been restored to capacity by the court after being ineligible to vote. The notice must require that it be returned if not deliverable”.  P. 386

I have never heard of a single situation where an election judge challenged a voter based on their mental capacity and do not understand how that would happen unless they were exhibiting signs of severe mental illness and were disruptive.

All these considerations point to the fact that voting and politics in the United States and elsewhere is a semi-rational process.  It was designed that way by the founders.  There are minimal qualifications to run for office - basically age, citizenship, and in some cases residency requirements. It is interesting that you cannot vote in many states if you are convicted of a felony but that does not disqualify you from running for President.  The top issues for most voters are not rational decisions.  I wrote a recent post on the fact that the President has little to do with the economy and an academic analysis showing Democrats were much better for the economy could not be explained rationally. That type of analysis can be applied to any of the top issues that voters are considering. There is one candidate who has been severely criticized for intellectual and character defects that include ignoring an attempt to overthrow the US government, lying for 4 years about an election outcome, lying more recently about disaster relief, and being convicted of multiple felonies. A significant number of voters and politicians in his own party elect to ignore these facts.  On the other hand members of his own party have endorsed the opposition candidate and actively campaigned for her. Forty of 44 cabinet and staff members of his own administration have said he should never be in the White House again.

This election exposes all the ugliness of American democracy that was previously not discussed.  All it took was a candidate who was more focused on himself and a few people at the highest income levels, disingenuous antiestablishment rhetoric, a lot of name calling, and some active obstructionism to real solutions.

My guess is the Founders of the Republic – did not see that coming.   

 

George Dawson, MD, DFAPA

 

References:

1:  2024 MINNESOTA ELECTION LAWS Office of the Minnesota Secretary of State, Elections Division. Annotations provided by Minnesota Attorney General.  Accessed on October 11, 2024.  https://www.sos.state.mn.us/media/5067/minnesota-election-laws-statutes-and-rules.pdf

 

Graphics Credit:

1:  Trump Photo:  Gage Skidmore from Surprise, AZ, United States of America, CC BY-SA 2.0 <https://creativecommons.org/licenses/by-sa/2.0>, via Wikimedia Commons" https://commons.wikimedia.org/wiki/File:Donald_Trump_(52250930172)_(cropped).jpg

2:  Harris Photo:  Lawrence Jackson, Kamala Harris Vice Presidential Portrait.  Public domain, via Wikimedia Commons" https://commons.wikimedia.org/wiki/File:Kamala_Harris_Vice_Presidential_Portrait.jpg

 

Lessons In Political Violence

 

I got tired of waiting for the American free press to provide an analysis of political violence in the country.  It is a huge omission in day-to-day discussions of the coarsening of American politics.  I was prompted to think about it as I was out driving around today listening to stories of election officials being threatened and manipulated as the federal election approaches, some to the point that they will no longer do the work that they have been doing for years. In a long-standing democracy why is this not front-page news?  Where is the analysis of the problem?  Who has an interest in suppressing the vote and why are they continuing to do this?  At the same time, I heard about a poll today saying that most Americans will not trust the election results – even though they are the most secure at any time in history and there is no evidence of suspicious activity.

Elections are not the only places where political violence is acted out in the US.  Abortion clinics – even during the days of Roe were places where women were harassed and doctors were shot and killed. Schools, teachers, librarians, and school board members are targets for similar politics with threats, work exhaustion, and ultimately moral injury when they are shouted down and threatened for doing the work that they are trained and licensed to do.  Public health officials are attacked for providing the best possible public health advice just because some politicians don’t like it or need to cover their own incompetence.  Since when is it acceptable for politicians to be inciting this level of violence against competent citizens with high levels of competence – who are just doing their jobs?   

Before proceeding I will define what I mean about violence.  The same people who incite it frequently minimize it after the fact using the rhetorical sleight of hand: “It is free speech and I can say whatever I want to say.”  Without invoking the famous Supreme Court quote – let me provide a little detail about definitions.  First, violence or aggression does not require physical act.  Aggression has components that occur on a strictly verbal level and aggression toward property or inanimate objects as well as self (2).  If you have ever witnessed any of those forms of aggression, you know why it is important.  It has a direct impact on you that can be long-lasting. Threats alone can significantly affect your sense of physical and mental well-being. Many states have terroristic threat statutes that can result in legal action before any physical contact occurs (see Minnesota statute below). Threats alone are a signal that physical aggression may occur and in many states it can result in visits from the police, orders for protection, and in the case of mental illness – involuntary holds and civil commitment. Interestingly, the political violence I described typically results in the victims trying to protect themselves.

What does interpersonal violence look like?  On a verbal basis it can be angry shouting like we have seen many times in televised school board meetings.  That can include name calling, personal insults, and profanities.  As the verbal aggression increases the insults gets worse to the point of threatening physical violence. That is evident in routinely televised road and customer rage incidents.  Whether it culminates in physical violence or not is not the point. For years the police tended to ignore verbal aggression and operated on the basis that the only type of aggression that counts is physical aggression.  Over the past 20 years there has been a more enlightened approach since verbal aggression is harmful and predicts physical aggression.  That has been associated with domestic violence and terroristic threat statutes.  In the main areas I have discussed the violence has increased to the point that the Department of Justice is aware of it and successfully prosecutes cases (3,4,5).

Social media has become another source of aggression and interpersonal violence. The popular press documents an explosion of hate speech on X (formerly known as Twitter) while the new owner Elon Musk denies it and claims to have reinstated both right wing and left wing posters as a "centrist".  In the meantime academics debate the definition of hate speech (6) but were still able to find 91 papers written about it on Twitter alone.  Violence and hate speech are probably best analyzed on a case by case basis and in my estimation there is no better example than the last two chapters of Anthony Fauci's book On Call (7).  In it, Fauci clearly describes how providing the best possible public health advice to the White House angered President Trump and the non-experts he hired to manage the pandemic. Fauci was politically scapegoated, derided by other Republicans and MAGA, terrorized at work and home, and ultimately threatened with incarceration for providing historically outstanding public health service to the American people.  MAGA politicians are still threatening to incarcerate him even though he is retired.  I encounter people to this day who "hate" Dr. Fauci - not based on any semblance of reality but the gross misinformation provided to them by MAGA.  That entire sequence of events flowed from Trump's anger that the scientific facts (masking, herd immunity, immunization) did not fit with what he wanted to tell the public.  This is exactly how political violence occurs.  

From a political standpoint, this violence and aggression is often rationalized as “free speech” and it is not.  Violence is often rationalized as the absence of physical contact.  That really minimizes the impact of significant unprovoked threats that can include threats to bodily integrity.   The current elimination of gun laws makes some of these situations even more dangerous.  To cite one example, there was an armed protest in front of a director of public health’s home and in this case the police did nothing.  How would anyone feel about have a group armed with assault rifles outside of your home saying there will be no violence “for now” because you are doing your legal job.

What I find missing from most of these discussions is the overall cause.  I do not think there is any doubt that it originates with one party or more specifically movement and their aggressive rhetoric essentially because they have no useful policy. That is as obvious as the continued denials of the 2020 Presidential election results and the high percentages of people polled within that party (88%) that have doubts about the current election.  We have seen the effects of their propaganda, repeated lies, and political violence on these systems and it is completely unnecessary.  It also causes significant degradation of these systems when long time competent professionals leave because of the threats and harassment.  

Political violence in the US is quite literally the elephant in the room.  And it is time to start talking about it that way. Where is the press with this analysis?

 George Dawson, MD, DFAPA

Supplementary 1:

I decided to include the current Minnesota terroristic threat statute as an example. Note that physical violence is not necessary.  I am no attorney but carrying assault rifle and saying that you are not going to commit violence "yet" would seem to be an indirect threat of violence.  

Supplementary 2:  My wife and I voted at City Hall today.  It was technically an "in-person absentee" ballot.  The process was identical to the one 4 years ago.  We provided several levels of ID including - Driver's License number, address, phone numbers, email address, and Social Security Number. The election official was separated from us in a separate room and all discussion occurred through a heavy glass window with a portal.  We presented an identification form.  When that information was confirmed the election official printed a label with verification that was affixed to the top of our ballots. We were advised to complete the ballot - seal it inside 2 envelopes using tape provided at the voting stations and then return it to her.  When we returned the ballot she personally signed each ballot with her name and address.  There was no public access to a ballot box or voting machine and the entire process was airtight.  I did notice that Robert F. Kennedy, Jr. is still on the Minnesota ballot along with several other third party candidates.

Supplementary 3:  Former President Trump's ad in 1989 directed at the Central Park 5 is another good example of political rhetoric obscuring the facts.   In this ad he discusses hating the suspects and wanting them executed.  They were subsequently exonerated based on DNA evidence and won a $41 M lawsuit against the city of New York for malicious prosecution.  

https://www.documentcloud.org/documents/6131533-trumpdeathpenaltyad05011989

Supplementary 4:  Updated graphic to include a number of false attacks on the Biden Harris administration and their handling of hurricane emergencies.   Many were ultimately refuted by Republicans including Republican Governors.  First responders and aid workers were described as demoralized.  This occurs two weeks after Elon Musk commented that  "no one is even trying to assassinate Biden/Kamala"  Musk subsequently said he was joking and removed the comment from Twitter but said he would not retract it.  The White House condemned it for condoning political violence.  In an age where you can not joke about bombs or terrorists on airplanes "jokes" about assassination should obviously be out of bounds.  I have seen people interrogated by the Secret Service for similar comments.   

  

Addendum:  There are so many of these incidents of violence out there I decided not to try to reference them all.  They can easily be found by Google searching the main heading like "election worker violence" and secondary elements.  You will get a lot of references and very little attribution to the political cause other than "divisiveness".   That word in itself should be telling because it is one of the main strategies of one party. 

References:

1:  Meghna Chakrabarti.  On Point.  "Elections officials endure protests, death threats. Here are their stories."  https://www.npr.org/podcasts/510053/on-point

This is the radio program I heard this afternoon.

2:  Yudofsky SC, Silver JM, Jackson W, Endicott J, Williams D. The Overt Aggression Scale for the objective rating of verbal and physical aggression. Am J Psychiatry. 1986 Jan;143(1):35-9

3:  USDOJ Election Threats Task Force:  https://www.justice.gov/voting/election-threats

4:  USDOJ.  Justice Department Addresses Violent Threats Against School Officials and Teachers

https://www.justice.gov/opa/pr/justice-department-addresses-violent-threats-against-school-officials-and-teachers

5:  Fraser MR. Harassment of Health Officials: A Significant Threat to the Public's Health. Am J Public Health. 2022 May;112(5):728-730. doi: 10.2105/AJPH.2022.306797

6:  Mansur Z, Omar N, Tiun S. Twitter hate speech detection: A systematic review of methods, taxonomy analysis, challenges, and opportunities. IEEE Access. 2023 Jan 25;11:16226-49.

7:  Fauci A.  On Call: A Doctor's Journey in Public Service.  New York, New York: Viking, 2024: 374-455.

If It Was 1968 – I could get a New Car for $2400….

 

Odd statement for a psychiatric blog?  I decided to address my favorite economic fallacy of election season and that is the effect of the President.  It came up as recently as four days ago in the Presidential debate.  During that debate – Trump claimed that he created the “greatest economy” and made the following statement:

“When I had it, I had tariffs and yet I had no inflation. Look, we've had a terrible economy because inflation has --which is really known as a country buster. It breaks up countries. We have inflation like very few people have ever seen before. Probably the worst in our nation's history. We were at 21%. But that's being generous because many things are 50, 60, 70, and 80% higher than they were just a few years ago.”

It was not clear to me if his statement abut 21% was supposed to be under his administration or Biden-Harris, especially when he makes the claim that “I had no inflation.”  That brings me to economic fallacy #1 in the Presidential race:

1:  Inflation is a fact of life in the American economy and there has never been a recent President with “no inflation”:

You don’t have to believe me. The evidence is abundant starting with retirement savings.  All the retirement advice you get gives you strategies on how to keep pace with inflation over the next 30 years.  There will be additional advice on how to keep up with inflation during your retirement years.  There is no advice that you can forget about inflation because it does not exist at times.  The title of this post refers to an ad for the Ford Mustang in 1964 that ran constantly on television with the title “$2,368 F.O.B Detroit.”  The starting price for a Ford Mustang today is $30,920. 

You don’t have to rely on those kinds of memories.  There is actual economic data tabulated.  The only problem is that it is not typically tabulated by Presidential term.  You must add that yourself.  I used the Bureau of Labor Statistics purchasing power calculator that uses a broad index of consumer goods to look at the last 7 administrations:

President	Years	Inflation
Biden	2021-2024	20%
Trump	2017-2021	12%
Obama	2009-2017	15%
Bush	2001-2009	22%
Clinton	1993-2001	24%
Bush	1989-1993	12%
Reagan	1981-1989	42%

 Inspecting those numbers – most people can come up with explanations for the variability.  Explanations of policies under any President responsible for the numbers is doubtful.  Reagan and his “trickle down” economic policies were a mainstay of Republican rhetoric for decades and he has the worst inflation rate.  The most likely difference between the Trump and the Biden figures was decreased demand and unemployment under Trump creating less demand and pricing pressure and then increased employment, financial incentives, and pent-up demand as the pandemic improved under Biden.

The rhetoric of the economy often leads people to come up with lists of commonly purchased items and how those prices have been affected.  First off – price inflation is expected irrespective of who is in the White House, but I encourage anyone to not take these lists at face value and do an easy recheck.  Here is one I did not too long ago after somebody posted their list of inflated items on Facebook.

Note that the GOP version in the first two columns does not match the prices I got off a Walmart web site on May 7, 2024.  The GOP version shows uniform increases in all prices between 2020 and 2024 and that is not the case.  Half of the items are less than they were in 2020 (see sparklines in last column).  Anyone can do this exercise when they see these postings about price increases of common items over time.  Secondly, there are factors that affect these prices that no President or country could conceivably control.  A good example is coffee.  Brazil and Vietnam are the largest producers and their production is currently affected by drought and climate change. Despite the current decreased production coffee prices are not as high as they were in 1976-1977 when over 70% of Brazilian coffee was affected by a frost and coffee prices doubled to $4.19/pound or $19/pound corrected to 2022 dollars. 

Do these lists really prove anything in terms of the candidates?  Not really because once again inflation is expected.  The political rhetoric is such that the GOP is portraying the current inflation as catastrophic.  Certainly, the higher end of the range that Trump describes has not happened.  A much more reliable index of inflation is available from the Federal Reserve.

The only relatively flat spot on that curve was at the peak of the COVID pandemic with decreased demand for goods and services. As demand increased the CPI increases and the Biden administration took over at that point.  The commonly quoted inflation numbers are consumer prices defined as: “Inflation as measured by the consumer price index reflects the annual percentage change in the cost to the average consumer of acquiring a basket of goods and services that may be fixed or changed at specified intervals, such as yearly. The Laspeyres formula is generally used “

2:  The most direct and sustained effects on inflation are initiated by the non-partisan Federal Reserve Bank:

The Federal Reserve Bank has been independent of political influence since 1951.   Between 1935 and 1951  “monetary policy would basically be dictated by Congress and the White House…”.  Even after that period, the Fed has come under pressure from the executive branch.  The Fed actions are a potent driver of the economy and check on inflation as evidenced by the following graphic on interest rate adjustments.  These interest rate adjustments are done based on macroeconomic rather than political considerations and many administrations have disagreed with them because they did not seem politically expedient.  Note the differences in interest rates over the past 2 administrations.  It is also generally agreed that the US economy has recovered post pandemic better than other high-income countries. Should an administration take credit for that or the Fed?

3:  Academic comparisons of the impact of Presidents on the economy show little effect.

The best-known study of the issue was done by Blinder and Watson (3).  They conclude that by all measures the economy does much better under Democrats in Congress and the White House.  It is not even close.  But they did not leave it there and went on to see if there was any clear explanation for this phenomenon at the policy level or based on the make-up of administrations and there was not.  They take it a step further and look at whether the economy was just poised for rapid growth at the time Democrats were elected and that was also not an explanation.  They consider various luck factors that are shocks to consumer expectations and find that makes up part of the difference.  In the end they find no complete explanations but suggest more favorable international conditions and consumer optimism may have something to do with it.  In short, the economy does better under Democrats but there is no clear explanation why that is.  Why then is it a top priority for the election?  The answer is that it is purely emotional appeal rhetoric with no basis in reality. 

Conclusion:

If you are really basing your vote for the President on the economy – find a different issue.  There is very little to no evidence that the President has much of an effect.  If you do your own research - there is a ton of information on this that is as accessible as doing a simple Google search on: “Does the President have any effect on the economy?”   There are papers, podcasts, blogs, interviews, radio programs, and more academic papers that say the same thing – probably not much if any of an effect. When I hear that polls suggest that most Americans think one party or another can manage the economy better – what is that based on?  A candidate saying that during his term he had the “best economy ever.”?  There is absolutely no evidence for a statement like that.

So “its not the economy stupid.”  Move on to another issue.  If you vote based on that issue – you are voting on unsubstantiated rhetoric,

 

George Dawson, MD, DFAPA

 

References:

1:  Overview: The History of the Federal Reserve.  September 13,2021:  https://www.federalreservehistory.org/essays/federal-reserve-history

2:  de Soyres, Francois, Joaquin Garcia-Cabo Herrero, Nils Goernemann, Sharon Jeon, Grace Lofstrom, and Dylan Moore (2024). "Why is the US GDP recovering faster than other advanced economies?," FEDS Notes. Washington: Board of Governors of the Federal Reserve System, May 17, 2024, https://doi.org/10.17016/2380-7172.3495

3:  Blinder AS, Watson AW.  Presidents and the US Economy: An econometric exploration.  National Bureau of Economic Research. Working Paper 20324, July 2014.  http://www.nber.org/papers/w20324

4:  Bilen C, El Chami D, Mereu V, Trabucco A, Marras S, Spano D. A Systematic Review on the Impacts of Climate Change on Coffee Agrosystems. Plants (Basel). 2022 Dec 25;12(1):102. doi: 10.3390/plants12010102.