Meeting of the Minds- March 27,2017

   This is the first of a series of reports recalling the highlights of the meetings of the Wise Guys, which are held every third Monday in Edmonds.  The discussions are generally no holds barred but polite and consist of the collective wisdom of the group. I have termed these jottings a Meeting of the Minds. 

   On March 27, the Wise Guys met in downtown Edmonds to discuss, as usual, aspects of public policy.  The topics included existential issues such as access to health care, the danger from North Korea and the disturbing influence of Donald Trump on the body politic.  As is usual these days, the specter of Donald Trump hung over everything. Particularly upsetting was Trump’s approach to truth, which consists of alternative facts mixed with mindless blabber.  We   hunger for the eloquence of Michelle Obama whose praise of truth is a treasured memory:  “We learned about honesty and integrity - that the truth matters... that you don't take shortcuts or play by your own set of rules... and success doesn't count unless you earn it fair and square. “ 

   We began with RN’s careful analysis of the Affordable Care Act. (ACA) On this day, there was some bright news.  The GOP’s version of health care had just been defeated. In fact it was never even brought up for a vote.  One cannot help but be drawn to the notion of resurrection after death, i.e. the death of the GOP program and resurrection of the ACA.  A more appropriate word would be transfiguration, which has implications for anticipated miraculous change.

   

   S.A. suggested that the demise of the Republican health plan might have salutary effects on the entire system. He suggested that bipartisanship might be required to rescue the ACA and thereby rescue America. The change in climate in Washington might represent a dose of political reality, sorely missing in our present political infighting. Perhaps, we will follow the lead of the Founders, who encouraged compromise to achieve acceptable outcomes,

   While discussing Donald Trump, the issue arose as to his mental state, in particular whether he is mentally ill. Such a diagnosis might impact on the 25^th Amendment, wherein presidents may be removed when judged to be too ill to function.  However, there is no agreement within medical circles as to the precise nature of Trump’s illness. However, the search for a particular diagnostic category pertaining to Trump is a fool’s errand. Mental phenomenology includes character disorders, neurosis and psychosis.  In fact there may be a blending of all of these disorders in any particular individual. Persons who have character disorders may slip into neuroses or even psychosis under stress. Thus Trump, who clearly suffers from a character disorder characterized by narcissism and sociopathy, on occasion, exhibits delusional thinking. Ultimately, the decision to use the 25^th Amendment to remove Trump from office would be a political rather than a medical decision. After all is said and done, we are alarmed by Trump’s mental instability, but no more so than his incompetence. We all fear the long-term damage to the country as a consequence of his illness and inadequacies.  We recall the words of Anthony, as he as he spoke of the recently deceased Caesar: “The evil that men do lives after them”

     The discussion of the ACA led to the issue as to what determines access to medical care. A recent article in the New England Journal of Medicine  2017; 376, 1307-1309   suggests that in urban areas, the issue is insurance availability, whereas in under populated rural areas, it is the availability of physicians that is the determining factor. Physicians tend to practice in areas they find attractive. Often it is where they lived and where they trained.   JB reflected that this issue could best be addressed locally rather than nationally. He described WAMI; a health governance attempt run by a consortium of northwest states including Washington, Alaska, Montana, Idaho, wherein the education of physicians is shared between minimally populated states. The education of students during the first of the non-clinical years is reserved for the teaching institutions of the individual states. UW in Seattle then completed the clinical years. This education sharing is meant to encourage educated physicians to serve as primary care physicians in their respective states.  The point addressed is that access to medical care is a complicated issue and requires a multipronged approach.

   JB concluded the meeting with a discussion of how to react to and manage North Korea. This hermit country alarms everyone with aggressive actions with nuclear capability. The Wise Guys were unable to suggest an effective strategy. Interestingly, none favored going to war, although this alternative seemed the only effective way to stop North Korea. Interestingly, Time magazine (April 3,2017,p.41-44) dealt with the same issue by reporting the attitudes of 6 highly skilled diplomats. They were no better than the Wise Guys in seeing a way out of this situation.

   Although all of the above issues defied resolution, the meeting did provide for a thoughtful approach to these problems, reflecting wisdom of age and achievement, the treasured characteristics of the Wise Guys.

Posted by Arthur Banner