The Times They Are A-Changin’ – or Are they?

I was walking around last week at dusk on a couple of nights. For the first time I decided to listen to some music as I walked. I would never do this if I was cycling because you need to hear the tire noise of approaching vehicles and I was using noise cancellation headphones tied into my music library. I also decided to use shuffle mode and that is also unusual – I typically repeat tracks until I get tired of them and that often takes a long time. For some reason, my phone kept playing Dylan songs. It reminded me of how I really did not like Dylan when I was young and listening to Hendrix and the Who. My interest peaked when he got the Noble Prize for Literature. It peaked again when I heard him interviewed and he talked about how easy it was to write music when he was younger. The music just seemed to flow and all he had to do was write it down. It was how mathematicians were described in Nasar’s biography of John Nash. Young mathematicians typically produced most of the ideas that advanced the field.

A lot of the songs were melancholy tunes about relationships gone bad.  Some were lessons in how not to be codependent. I was acutely aware of being an old man dressed in black listening to this music and free associating to similar events in my life from long ago. Before it got too maudlin - The Times They Are A-Changin’ came on:

Come gather 'round people

Wherever you roam
And admit that the waters
Around you have grown
And accept it that soon
You'll be drenched to the bone
If your time to you is worth savin'
And you better start swimmin'
Or you'll sink like a stone
For the times they are a-changin'

I could have sworn that what I heard walking around in the dark was a direct reference to the United States in that song. But looking it up later - it was not there. The song snapped me out of interpersonal reflection and into the current threat to American democracy.  For the past several days I had been responding to social media posts about the disconnect between what appears to be going on in national presidential politics and the reality of the situation. Just that day I responded to a poster questioning why Christians appear to be in lock step with a candidate who does not appear to have similar values and how Biden has done very well in the White House but seems to be struggling in the polls against a candidate with a known poor record who orchestrated an insurrection against the US government? A candidate who has been charged with 91 felonies. Even more mysteriously, the entire Republican party with rare exceptions is supporting Trump and most want his endorsement in local and state elections. How can a candidate with that many flaws still be in contention at this point and dominating a party that was originally abolitionist and got Lincoln elected as their first President before the start of the Civil War?  It does not make any sense and I will look at the hypotheticals below.  I tried to put as many as possible into the graphic at the head of this post – but only the coarsest details are possible:

1:  A general lack of critical thinking:

It has been a long time since I took a high school English class, but from what I recall even back in those days there was very little emphasis on rhetoric. Critical thinking generally involved the decoding the author’s intent, detection of symbolism and defending an opinion on a theme: “Do you find Lord of the Flies to be optimistic or pessimistic and why?”  Rhetoric was largely confined to debate teams that a small percentage of students participated in.

It has never been more important for the average citizen to be informed and aware of what might be rhetorical distortions. There used to be some level of assistance from professionally edited news, but that is no longer reliably available. Today it is possible to get all your news from a site that you agree with on ideological grounds – no matter how far from reality that site gets. Apart from these echo chambers on the Internet, the main street news offers minimal assistance.  You might find stories about the polarized electorate with no discussion of what that means or if one side is more polarized than the other.  Threats and overt violence were introduced into the political scene with no comment that this is almost an entirely right-wing phenomenon that is often tied in with gun rights and bragging about who owns the most guns. The right wing owns both moral and gun extremism in the US and yet there no criticism of this in mainstream media. Most importantly, political violence against specific groups should be unacceptable in the US and it is increasingly apparent.

2:  President Biden is too old: 

This seems to be a popular trope in both campaign propaganda and as material for comedians.  Bill Maher for example, will often detail the accomplishments of the Biden administration as being some of the most significant in decades only to incorporate polling questions about his age and conclude he should step down and let someone else run. No suggestions about who that should be and judging from the declared candidates there is no one of suitable name recognition or accomplishment who could run and expect to get support equal to Trump’s locked in MAGA constituency. If you look at my graphic – any candidate the Democrats advance will not have the amount of leverage with the voters based on the factors listed.

But backing up – is 80 years old – too old?  I saw President Biden on the bike and I saw him fall. It was clearly a mistake that people make when they are not used to toe clip pedals. The part that most people seem to ignore is that he got up with no problems. That is not the mark of a feeble old man and neither is the current schedule he has been keeping. More to the point – he has an awareness of how things need to run in the Executive Branch, how information needs to be managed, how consultation with staff is a critical function, and how to manage alliances.  There is minimal evidence that his predecessor has that level of awareness.  

There is certainly no current evidence that Biden cannot do the job given his list of accomplishments and some high-profile incidents – most notably his performance at the last State of the Union address. Ageism is certainly a prominent cultural bias in the US.  If I were a foreign actor wanting to manipulate the American electorate – I would use it, especially if I knew the opposition party could easily be convinced to use it.  The current group of Republicans could be expected to jump on it even though some of their members of Congress are older than Biden.

3:  The Republican base has been manipulated and brain washed by culture war tropes: 

This is undoubtedly a factor at some level.  I have written on this blog about how the GOP has become a party of gun and moral extremists – not out of some strict Constitutional interpretation or religious belief, but out of political expediency. It is easy to manufacture some ideological position to elicit emotional responses from some voters and get them to believe they are in a morally or Constitutionally superior position. Fortunately, that is not how democracy works but it is how the current crop of Republicans want it to work. In the meantime, public safety, education, and women’s health have all been compromised. On the day I am typing this a Constitutional Amendment for reproductive rights was passed in Ohio blocking attempts to pass restrictive abortion laws. Whether this can be a rallying point against moral extremism is an open question at this point.

4:  Fragmentation among Democrats: 

There is some concern that progressives within the party have gone too far in areas of social consciousness particularly social justice issues involving race and the LGBT community. The concern is amplified by the Republican’s rhetorical use of the term woke as a pejorative. That has allowed them to indiscriminately use the term to criticize health care, educational, social, and economic policies as being too woke (translation politically correct) and simultaneously suggest that most Americans would not find it to be acceptable. That can range from books in a high school library that were read by several older generations to college admission policies to protests about excessive use of force by the police.

The current war between Israel and Hamas is a similar flashpoint. One analysis suggests that progressives see the world though a simple lens of colonizers and victims. That has been spun into Israel starting a genocidal war in Gaza or even the US starting or backing such a war. In the most extreme case, social media was abuzz with young people supporting a letter allegedly written by a famous terrorist, blaming the United States for terrorist attacks. That has also led to protests and threats to Jewish college students in the United States. All of that misses the point that violence is being incited against US citizens who happen to be Jewish and that Hamas clearly started the war and clearly stated their ongoing goal is to destroy Israel and kill their citizens.

5:  Activation of far right white supremacist and antisemitic groups:  

There is no doubt that fringe groups that were essentially silenced for many years were activated during the Trump administration and actively support him. In my own neighborhood there was widespread dissemination of white supremacist literature for tens of miles in all directions.  That has never happened in the Midwest during my lifetime. Further investigation linked the same group spreading that literature to antisemitism.  Investigation by local officials and law enforcement did not identify the specific perpetrators and no charges were ever filed.

6:  Activation of antisemitism in younger generations: 

The facts are not disputed and various theories have been proposed. The history is forgotten explanation seems to have a lot of traction.  At least it seems to have garnered the most speculation. In other words, with less exposure to Holocaust survivors and the history of World War II, younger generations are unlikely to believe the actual historical events – a clearly documented genocide against the Jewish people. That seems to minimize any role of activated antisemitic hate groups and social media. Many of these groups are now at the point that they show up in public demonstrations and are attempting to recruit new members from suburban neighborhoods. The wave of antisemitism in the younger generation has had far reaching effects on college campuses, in some cases to the point that departments and administrations failed to condemn the recent terrorist attack against Israel or an obvious problem of antisemitism on their campuses. This generation uses TikTok as a preferred social media site. In a recent press release they described removing tens of thousands of antisemitic posts.  Just how long that posting has occurred is unknown.

I think it is also useful to recall that political violence directed at minority groups is a well-known tactic of fascist and totalitarian states.  In the early days of the Internet online discussions often became heated to the point that accusations of Naziism were often made.  This led to Godwin’s Rule or as an online discussion grows longer (regardless of topic or scope), the probability of a comparison to Nazis or Adolf Hitler approaches 1.  That is basically nerd speak to say that analogies to Nazis based on Internet discussions is probably absurd. What I have seen lately suggests to me that we are beyond the absurd stage when people are injured and living in fear.  If it walks and talks  like a Nazi….

 7:  The social media propaganda machine:  

Social media seems to always be in the news. The common topic is how it is a malignant force in the lives of teenagers and children. There is concern that you can get “addicted” to rapidly scrolling and clicking on too many sites. People talk about the dopaminergic effects of this activity – like the neuroscience is known. Even though we had a foreign government actively interfering in the last Presidential election through social media and email hacks – nobody seems focused on that happening again. US Intelligence agencies predicted that it would happen again and it would probably be more vigorous than the last time. It is also more difficult to detect because the foreign actors are all using servers within the United States. Several agencies are responsible for detecting and monitoring this activity – but 1 year out none of them are reporting on what they see or what kind of misinformation is being posted. You don’t have to be a secret agent to think about who these foreign actors are. Russia was clearly involved in the last Presidential election and given the situation in Ukraine – they would clearly prefer Trump over Biden.  Putin has actively encouraged Russian hackers at all levels including those who steal money from average Americans.  Trump has made it clear that he would not support Ukraine and he clearly had a negative impact on NATO.  Biden has been able to reverse most of that damage and unify NATO.  Iran, China, and North Korea also have an interest in a Trump presidency.  These countries either have a direct interest in supporting Trump based on his probable policies or just weakening the US by more divisiveness in the electorate.

 8:  Uncritical voters:  

I heard Iowa voters asked about why they are voting for Trump and why he is so popular in their state.  I heard the following responses:

 “He is a businessman.”

 “He says what is on his mind.”

 “I don’t care what he has said or done – I am voting for him.”

These responses and his previous performance – all indicate that many Trump voters are not focused on any policy.  It would probably be difficult because most of the policies that Trump seems focused on at this point have to do with revenge against his perceived enemies.  That is typically a low bar – they are people who either disagree with him or want accountability.  That leads me to a previously stated conclusion I made that a lot of Trump’s base are nihilists who just want to burn the system down. It is difficult to find more nihilistic behavior than orchestrating an insurrection against the US government and refusing the peaceful transfer of power.

Given the above analysis – I think the negative sentiment about President Biden is primarily the product of foreign actors manipulating the American electorate. That also explains the disconnect between many of the demographic features of Trump voters and their candidate.

I do not want to put all of this on young voters.  There are clearly older voters who demonstrate similar levels of cluelessness, probably borne out of long-standing biases.  It is up to voters of all ages to not believe what you see in social media echo chambers, clear propaganda from hate groups, and similar attitudes that may have existed in your culture for generations. We cannot turn the United States over to a man and a party of extremists who have proven time again that they have no vision for the country or where it is headed. In Congress the Republican majority has clearly demonstrated that they cannot govern. We cannot be influenced by groups seeking to divide Americans and destroy the values that this country was founded on.

We all must start swimmin’ to save American democracy.

 

George Dawson, MD, DFAPA

References:

1:  Hotez, Peter. "On Antiscience and Antisemitism." Perspectives in Biology and Medicine, vol. 66 no. 3, 2023, p. 420-436. Project MUSE, https://doi.org/10.1353/pbm.2023.a902035.

2:  Scherer, Nancy & Miller, Banks. (2009). The Federalist Society's Influence on the Federal Judiciary. Political Research Quarterly - Polit Res Quart 62. 366-378. https://doi.org//10.1177/1065912908317030. 

Graphic Credit: I made this graphic 

Supplementary 1:  Why I wrote this post - this post is not an analysis of the psychiatric status of either candidate.  I am on record on this blog that the role of assessing the President's fitness to work in that office is supposed to be assumed by lay people working with him or her.  Many people working with Trump have provided scathing critiques of what they observed. I have not seen any from the Biden administration. 

This post was written basically as an exploration of how a candidate who seems so intellectually, emotionally, and temperamentally unfit for the office (as determined by multiple independent assessments by non-mental health professionals) has such a draw with the electorate. It seems mystifying until you look at the diagram and realize that more of the factors that leverage the electorate are stacked against Biden rather than Trump. In fact - replacing Biden in the graphic results in minimal gains. If I had to speculate on the biggest effect I would see it as all of the factors impinging on the social media on Trump's side.  

For the record, I am not a life long Democrat and in fact ran as an Independent in 2000 for the US Senate from Minnesota. As a life long skeptic of both major parties, that was an eye opening experience. I am currently highly motivated to write about political extremism that I see from Republicans and the fact that it is only getting worse.  Giving Trump the job again when we already know what happened the last time is a clear mistake.  Allowing the Republican Party to maintain a nongoverning, culture wars, nihilistic response is also a massive mistake for the Republic.   

 

Supplementary 2:

Will add some examples to highlight the graphic as the I see them on a day to day basis:

Taylor Lorenz - excellent example that I saw today on TMZ is this interview.  Before this the TMZ crew showed Biden's attempt at humor with a birthday cake and they continue this into the interview like he is trying to win young voters with jokes.  Ms. Lorenz of course jumps on the opportunity to point out that Biden has not been focused on what Millennials or Gen Z want.  She cites an example of student loan forgiveness was not a focus apparently forgetting that his $430B student loan forgiveness plan was shot down by the right wing Supreme Court.  All three justices appointed by Trump (Gorsuch, Kavanaugh, Barrett) voted against the plan in a 6-3 vote (Biden v. Nebraska).  Instead she praises Trump for being "authentic."  With brilliant analyses like that Biden does not stand a chance. 

Adam Kinzinger - seems like a rare positive force in American politics today.  I saw him on Real Time with Bill Maher last week where he clearly stated that there was only one pro-democracy political party in the US and it was the Democrats. The former Republican Congressman clearly described why fanaticism is a negative coercive force in politics and that is why it needs to be eliminated. He also founded the Country First PAC as a way to distance himself from right wing extremists and conspiracy theories. 

Gen. Mark Milley - questioned about President Biden's performance by 60 minutes.

Physician Generational Effects of Oppression By The Managerial Class

One of the dynamics that I consider to be essential to the survival of the profession is whether there is any way to resist the manipulations of the managerial class.  Since the profession has been almost completely subordinated to the managerial class, the question may not seem very relevant.  Too much depends on physician independence to give it up that easily.  Without physicians independence there is really nobody advocating for our patients.  Do we really want to be cogs in a government sanctioned business empire that decides when people live and people die or who gets medication or who gets reasonable medical care?  There is no physician I know who is willing to give those decisions up to administrators.  Those decisions are happening by manipulation and default every day.  Administrative representatives sitting in on medical teams with the full blessing of the CEO or department head.  Cross them and you may be out of a job either directly or pressured out by becoming person non grata or a handy "disruptive physician" label.  That is a high price to pay for disagreeing with management, especially when they are making decisions that only a physician is trained to make.

I have had the opportunity to work with residents and early career physicians for about the past 15 years and I noticed that they had a tendency to get a lot less riled up about these scenarios than I did.  It is paradoxical in a way.  Even though older physicians tend to be much more bothered by the managerial class than our younger colleagues, all of the burden of these managers is falling directly on them.  Electronic health record (EHR) mandates, EHR software that is essentially junk, arbitrary maintenance of certification (MOC) requirements, billing and coding requirements to avoid financial penalties, and on and on and on.  The burden of the managerial class on physicians gets worse every year and there is no end in sight.  There has been very little resistance to this burden.  The only exception that comes to mind in the National Board of Physicians and Surgeons - an alternate route to maintenance of certification through standard life-long learning approaches rather than the methods recommended by the American Board of Medical Specialties (ABMS).  The NBPS was founded by Cardiologist Paul Teirstein, MD who graduated from medical school in 1980.

As far as I can tell there is very little research on the generational effects of changing physician demographics.  By that I mean - how are the specific groups of physicians impacted by excessive management, do they react to it, and do they have any success in changing it in a positive way for physicians.  The raw data on physicians based on Census data is fairly interesting.  The population of physicians is fairly stable between the current age range of 34-59 with a more even distribution of men to women starting with 32 year olds.  That distribution has been more even in psychiatry than more other specialties for much longer - at least the departments that I have worked in.

Using standard generational nomenclatures that means that there are still physicians practicing who were born in 1945 or earlier (72 yo and greater).  The Baby Boomers are in the 53-71 yo range.  Gen X are the 41 - 52 year olds.  The Millennials are 22-40.  It looks like there are also a total of 34 Gen Y physicians who are currently 21 years of age.  All of the named generations seem to be represented.  I don't put much stock in generational characteristics being applied across standardized age ranges.  Certainly younger physicians are more likely to text and use more Smartphone apps, but it really is impossible for physicians practice these days and not have more than a passing command of basic technology.  If they don't know it and the implications, they will probably have to be trained in it.  

The demographics are available but outside of the burnout literature, there is very little written about the generational effects of management.  These are important questions because non-medical business management has unprecedented influence on medical care in this country.  Business managers determine how long people get to stay in the hospital, how much time physicians have to spend on documentation and record keeping, how many patients physicians need to see each day, and the entire structure of outpatient medical care.  A great example is how psychiatric practice has changed from seeing patients fairly frequently and discussing many aspects of a persons care to isolated brief appointments to discuss a medication that may be only moderately effective.  If you see a medical specialist - you might be limited to one appointment per year.  Business managers have widely implemented team approaches and sold this idea to the public.  What the public does not know is that there are management representatives on these teams who lack medical credentials and given that fact have a disproportionate amount of input into patient care.  Physicians are micromanaged at every decision point.

My real question boils down to what happens when that case manager on your "team" tells you that the patient needs to go and as a physician you know they are not stable and can benefit from continued care?  How does a 53 - 71 year old physician react to that dilemma compared with a 22-40 year old physician?  Are there intergenerational conflicts based on those reactions or the perceptions of those reactions?  What are the reality factors involved?  I know that there are plenty of anecdotes.  It is common to hear that Boomer generation physicians are retiring as soon as possible to avoid oppression by managers.  It is also common to hear that Millennial generation physicians are laboring under unprecedented levels of medical school debt.  That plus a mortgage and a family gives them limited options in responding to oppressive management practices.  That is especially true when short staffed hospitals offer signing bonuses to early career physicians.  There is some intergenerational conflict on the maintenance of certification (MOC) issue.  The Boomer generation is more likely to be incensed and point out that there is really no "evidence" that the requirements made up by the ABMS are necessary.  Some of the younger generation is critical of the Boomers, especially about the fact that many are "grandfathered in" based on age.  There is no more critical issue for all physician generations and the political forces that have the most to gain from MOC are just waiting for a generational split to give them the advantage they need to continue their agenda.

The other movement is an exodus of physicians into private practice and in some cases cash only practices or some variation.  That is a definitive way to escape oppressive management practices, but the managers and their friends in government have a long reach.  The electronic health record (EHR) is one example.  Even though the EHR remains not ready for prime time for a number of reasons, it is mandated for use by physicians and pharmacies.  It is a relatively new cost for any physician or group who wants to try to make it outside of the systems of government payers, managed care organizations, and pharmacy benefit managers.  Finding an EHR that has more value than problems is a daunting task.  It is probably the most imperfect software that you can find anywhere.

Those are a few thoughts on this is this Saturday morning.  Make no mistake about it all physicians are targeted for oppression by managers at some level.  On a daily basis it is not difficult to find some business entity that has made a bad decision about the care of one of your patients or one that is not actively trying to interfere with your care of a patient.  In some cases, the physician is just an afterthought.  They are swept into the battle between pharmaceutical benefit managers and pharmaceutical manufacturers over medication pricing structure and how it is reflected in the written prescription.  But all of that still comes back to the physician when they are ordered to make what amount to trivial but time consuming changes.

The goal of examining these issues would be to get rid of micromanagement initially.  There is no reason why prescriptions for inexpensive generic medications should be micromanaged.  It amounts to harassment.  It seems more complicated if we are talking about teams where a manager is sitting in a team meeting and dictating care, but it is not.  Most of medicine these days is still based on subjective decisions and experience.  That may not seem to fit into the rhetoric of evidence based medicine, but it is the property that currently gives physician the advantage over computers.  Recognizing experienced based patterns in patient diagnosis and care is the reason that medical training is necessary.

Business managers don't have it.  Looking at the generational effects may give physicians some ideas of how get rid of some of these practices and present a more united front to the people adversely affecting our care of patients.                



George Dawson, MD, DFAPA  



Reference:

1:  Carol A. Bernstein.  The Changing Face of Medicine: The Next Generation of Psychiatrists.  Keynote address.  Minnesota Psychiatric Society October 8, 2010.