Cancer Screening As "Insurance?"

This is a bit long for a Twitter thread, and I'd like to be able to reference it.  

I intend it to be tentative, hypothetical, a bit of a question.  However, it is written as an argument, a statement, since that is easier, I think, than having every sentence an awkward query or with too much of the necessary language of uncertainty.  Please read it in that light.  

I don't bristle at being corrected, but welcome it. Further, I take the time to write this out since I haven't seen it elsewhere.  If the central point made exists in another form elsewhere I would appreciate being directed to it. 

An additional caveat.  This is through the eyes of the risk-cost/benefit to an individual patient — the fully informed rational patient, if you will.  I realize there will always be charlatans selling promises and the "worried well" willing to buy those promises.  

This all said, there was a recent New England Journal of Medicine randomized control trial of colon cancer screening in three European countries that caused a stir (1).  This is not directly an analysis of that study, nor of colon cancer screening per se (which is a broader topic), but it prompted a few thoughts. 

First, as to the state of the art, using colon cancer screening as the example.  Below I link to this paper on colon cancer screening by Zauber(2) from 2010.  It is a rich analysis, and she is evidently quite prominent in this field (3).  One of the obvious limitations — see below, as well — to the cost effectiveness analysis she uses here is that the prices in dollars, while real, are somewhat arbitrarily set by CMS, etc.  There is no "price mechanism."  Further, these analyses run the risk of becoming a population utilitarian calculus only.  One also runs the risk of attempting to quantify things difficult if not impossible to quantify.  

Nonetheless, here you'll find talk of "discount rates," years of life saved (i.e. taking into account the age of finding the cancer), the "efficient frontier," etc.  She attempts to account for the costs of complications, as well. It's not perfect, but much more sophisticated than simple talk of absolute risk reduction or effect on overall mortality.  Obviously, it does not take into account last week's study.  However, this type of analysis is the backdrop. (4)

Still — and this is my primary point here —there is no taking into account the costs/benefits from strictly the individual viewpoint, or that one cannot simply buy the average.  An individual either dies from colon cancer prematurely or does not.  The average benefit obscures this.  

 So, a few risk management type thoughts on this:

I).  The age at time of death is not normally distributed.  See the above graphical image.  I think the intuition is that most of us would like to improve the chances of having good quality of life up to the modern mode – i.e. the most common age of death, which approaches something like a full potential life —  rather than simply add on months/years at the end of life.  So, part of that goal is to reduce the risk of being in the long left side of the curve.

II).  Population based studies are obviously necessary to determine efficacy, but, on the other hand, one cannot buy the index.  In which case, a screening tool (and we're only talking about a few common tumors here: breast, colon, lung, prostate, cervix) that can decrease the chances significantly of pre-mature death at reasonable total cost for that one relatively common cancer acts a bit like the risk management tool of "insurance" from the individual standpoint — since one has only one life.

III)  There is still a cost/benefit, but it's more nuanced than a population average applied to the individual.

Here I’ll attempt to flesh out the argument a bit more, if not obvious, re "insurance."  

Term life & homeowner’s are good products despite having a negative expected value. If one owned 10,000 residential homes across the country, however, as some sort of rental empire, homeowner's insurance is a bad deal.  I own one, so it's wise.  The owner of 10,000 homes saves on the insurer's profits and overhead minus claims paid.  The individual homeowner pays the premia to share risk, hoping to never need the big payout. 

Now, the average patient won’t get or die from, in this case, colon cancer, so why bother?  However, no one gets the average benefit, the little benefit, one gets a big benefit or zero.  Each individual is a bit like the individual homeowner who cannot diversity his risk.

In an effort to think through heterogeneous phenomena clearly, and put yet another way, one realizes the aim in the case of these relatively common cancers is not to bend the risk curve of something ultimately near universal if one lives long enough (atherosclerosis) but to significantly decrease the chances of that one particular cancer from ending one's life prematurely.  

If one's goal is to reduce the odds of avoidable premature death, then as long as the disease is relatively common and occurs at young enough ages, the screening tool significantly effective at detection/disease-specific risk reduction, and not terribly onerous, then the overall mortality rate reduction (nice if you have it, certainly!) may very well be the wrong measure, if viewed through the above lens.

In this sense, it is a bit like insurance — not with a financial payout for a rare idiosyncratic catastrophic outcome (e.g. house fire), but in preventing premature death from that one thing.  Again, like with insurance of individual homes, we’re all individuals unable to diversify our risk.  No one gets the average outcome, and some leave decades of  good life on the table.

(To be clear, unlike insurance, it is not a pooling of risk for a price, so the analogy is not precise. Perhaps one can also think of an analogy to maintenance/inspection of equipment to avoid rare, but critical, as opposed to just expected mechanical failures?  However, this too has its limitations).  

Further, and to reiterate, we can only effectively screen for a handful of relatively common tumors, this is not an argument to do frivolous, worthless things out of a fear of premature death, just an attempt to describe the goals in a way that captures the intuition a bit better.

There are, of course, significant quantification challenges.  Ultimately, I suspect quantification is in a full sense impossible, or should be seen as an approximation, a shorthand at best. 

In the Zauber paper referenced above, and which I highly recommend reading, in addition to the issues raised above, dollar costs are used for costs, whereas costs also include time, appointments, inconvenience, discomfort, false positives, distress, etc.   

And, certainly, the rare costs of complications are not adequately denoted in dollar signs! 

The advantage of using costs in dollars, however, is it allows for quantification, for calculating the discounted costs and benefits, for calculating the "efficient frontier," for calculating the cost per quality of life year saved.  The disadvantage is it tends to simplify both those costs and benefits.  

It also misses, I think, and as I note above, the "insurance" point.  Yet, even for insurance type instruments and products the costs/benefits are not always clear.  Term life, particularly for the household’s breadwinner, and homeowner's insurance are fairly straightforward.  Others less so (5).

The challenges to quantification should not discourage us, however, from thinking as clearly as possible about the phenomenon in question, our goals, the potential costs and risks, about risk management, and about the potential benefits. Further, we should not settle for a flattened, overly simplistic analysis out of a desire for ease in calculation. 

And, of course, one should not neglect the obvious point that costs and benefits in an innovative, dynamic system are themselves dynamic.  

The ever important, if thorny, issue of who calculates the risk/benefit and who pays is another topic altogether.

Lastly, one brief statement regarding populations as collections of individual patients vs. populations per se.  We are physicians with individual patients who come to us seeking guidance and care, not gardeners cultivating our fields and maximizing the yield.  The former is Medicine, the latter something else entirely:  the wrong path. 

1Effect of Colonoscopy Screening on Risks of Colorectal Cancer and Related Death

2 Cost-Effectiveness of Colonoscopy

3 Ann Zauber, PhD

4 For those unfamiliar with these financial economic terms, consider Wikipedia links to

Efficient Frontier & Modern Portfolio Theory & John Cochrane's influential address on Discount Rates

5 Consider the debate between Nassim Nicholas Taleb and Antti Ilmanen on whether or not the returns from writing options on indices during normal times are worth the cost during market downturns — i.e. whether it is better to sell or buy such "insurance." That University of Chicago PhD’s and Taleb — with skin in the game — have no small disagreement on this issue regarding a long-traded financial instrument points to the challenge. 

Taleb here:  No, Small Probabilities Are Not "Attractive to Sell": A Comment 

Ilmanen book: Expected Returns  

Bloomberg coverage of  a Twitter spat "Taleb Spars with Asness"

Specialist/Generalist Psychology in Life

Sunday thought re the psychology of “generalism”/specialism, breadth/depth, not just in e.g. Medicine, but life. 

We are most of us specialists in life, given modern economics.  Division of labor is a great source of wealth, but also of “knowledge production.” 

Yet, we all see specialists who are expert in their niche, and know little outside of that particular world.  i.e. Specializing can be distorting.  This might be heightened today, but is likely as old as the beginning of civilization (as opposed to hunter/gatherer societies?).  If memory serves this is Allan Bloom’s interpretation of Eryximachus’ speech in the Symposium.

One necessarily sees the world through the methods, concerns, and magnified concentration of one’s specialty.  To use a trivial example, I know few cardiologists over 40 who do not themselves take a statin, regardless of lipids or family history.   Other examples are likely easy to think of.

But, as in Eryxcimachus’ speech, there is also a tendency to see one’s niche everywhere, apply one’s knowledge inappropriately to the wider world.  Further, to assume if one is bright here, one’s opinion simply translates to there, with very little work.

Since we are most of specialists, one remedy may be to try to develop the habits of a lifelong general education; to work to understand other fields more deeply, on their own terms.

On the other hand, but relatedly, the danger of “a little knowledge” is the tendency to think this is adequate.  The generalist might mistakenly think reading one book/article, etc. leads to an understanding of the area.  Trial lawyers who try complex cases – specialists in the courtroom, generalists in knowing about various part of life, industries, etc. – sometimes fall prey to this.  They need to be bright enough to understand the issues at hand, which can lead to an overconfidence in one’s real understanding of the field.  So, while specializing can distort how one sees the world, “generalizing” tends to simplify, flatten, misunderstand without self-awareness.

Every specialist knows this when they hear an outsider discuss their own area of specialization.  It is at best 85% accurate.  Even the best non-M.D.s discussing clinical Medicine to the ear of a physician?  At best an approximation, and typically worse.   In which case, if one recalls this as a specialist, the specializing itself can be a guard against hubris regarding other areas of specialization. 

So, while specializing can distort and “generalizing” can be overconfident in its understanding, can they also tend to correct each other, if one guards against the pitfalls, if one addresses this specialist/generalist psychology with care and humility? 

Might the best thing for the specialist be more general knowledge -- but also vice versa?   

10 Best Christmas Movies

11.  Die Hard

10.  3 Godfathers (1948)

9.  Elf    

8.  A Christmas Carol (1951)

7.  Santa Claus Is Comin' To Town

6.  Home Alone

5.  A Christmas Story

4.  Miracle on 34th Street

3.  National Lampoon's Christmas Vacation

2.  A Charlie Brown Christmas

1.  It's A Wonderful Life

25 Greatest Films of All Time

Hey, make your own list. 

Heavy in some genres, light in others.  To be amended freely in the future.

1   The Searchers

2   Vertigo

3   Casablanca

4   The Treasure of the Sierra Madre

5   Double Indemnity

6   The Godfather

7   Citizen Kane

8   Groundhog Day

9   It Happened One Night

10  The Wizard of Oz

11  La Strada

12  The Third Man

13  The Godfather II

14  The Man Who Shot Liberty Valance

15  North by Northwest

16  Fort Apache

17  Rear Window

18  It’s A Wonderful Life

19  From Russia With Love

20  Raiders of the Lost Ark

21  Caddyshack

22  The French Connection

23  Apocalypse Now

24  A Serious Man

25  Being There

Groundhog Day Links

After writing about Groundhog Day, I did hunt around to read a bit about the film.

Interestingly, it seems that the final product was really a collaborative effort between the screenwriter, Danny Rubin (who had written a very different script), Ramis, and Murray.  Ramis, of course, directed its development from the original script, but Murray was difficult and insistent about the character, and the result was the film as it is.  Murray was so difficult, that he and Ramis - despite their long relationship prior - did not speak again until the end of Ramis' life.

I am posting a few links.

First, as expected, Wikipedia has a long entry which is helpful, and has 76 references.

Here's an interview with the screenwriter, Danny Rubin.

Of course, Mark Steyn knows and enjoys the Brigadoon reference.

A 2003 NYT article about a MOMA conference on God and Film opening with Groundhog Day.

Jonah Goldberg at the National Review on the film.

An oft-cited piece which is really quite good and worth reading on the themes, but takes a few missteps - the local man named "Gus" is clearly short for Augustine?  Unlikely.  The analogy regarding the "shadow" cast by the two Phils is excellent, however, and obvious in retrospect.

Another Christian piece that reflects on the nature of and possibility of human virtue in a fallen world.

A four minute video of Ramis about the film.

Last,  a long 80 minute video where Ramis is presenting at a conference on cinema.  At 1:09:30 he speaks about his personal quest for meaning - and for laughs.  It's worth watching if you think that Groundhog Day is explicitly certain about a cosmic teleology — as opposed to nature being consistent with the possibility of one.

Groundhog Day and the Pursuit of Happiness

"If I am not for myself, who is for me? And when I am for myself, what am ‘I’? And if not now, when?" (Hillel)

“There is no truth more thoroughly established, than that there exists in the economy and course of nature, an indissoluble union between virtue and happiness” (George Washington, First Inaugural, 1789)

I first saw Groundhog Day – directed by the late Harold Ramis, and starring Bill Murray - during its initial theatrical release in 1993 and have seen it multiple times since but until last week had probably not watched it in fifteen years.  This is despite my, only somewhat jocular, frequent reference to it as the greatest film of my lifetime.  I am spurred to write this by that viewing – and given my pace with such endeavors – in anticipation of 2018 marking its silver anniversary. 

Now, much ink must have been spilled already regarding this film.  As far as I can remember, I have not read any of it and have at this writing purposefully avoided searching the internet for reviews, interviews, essays, analyses, etc.  I will perhaps post an addendum after initially posting this if I do search out the views of others.    My point is only that I intend this as my stab at interpretation, relatively uninfluenced. 

Lastly, by means of introduction, this is an analysis, not a review.  One of the great achievements of Groundhog Day resides in its restraint, in not telling us what it is doing, but in showing us.  In doing so, it can be enjoyed on several levels, like the best works of fictional literature, be they epic poetry, novels, plays, films, etc.  Herein, I exercise no such restraint, so spoiler alert for an old movie:  please watch it first if you haven’t already! 

How to describe Groundhog Day?  It is a comedy, albeit a contemplative one, with a romance.  Is it a version, then, of that cinematic staple, the Romantic Comedy?   In a limited way, some aspects of both the contrasts and developing rapport between Phil and Rita are reminiscent of the interplay we see with classic couples in movie history such as Clark Gable and Claudette Colbert’s characters in It Happened One Night.  However well Murray pulls off this element of comedy, we shouldn’t stretch the comparisons.  Groundhog Day is certainly not a conventional romantic comedy, or at least it is much more than that.  It, however, is undoubtedly a comedy - and my serious tone shouldn’t allow one to lose sight of the fact that it is quite simply side-splittingly funny.  Since, historically, dramatic comedy can tackle also serious themes, we might think of Groundhog Day as being temperamentally somewhere between Aristophanes and Shakespearean comedy; and, of course, we may also rightly conclude that fitting into a genre is unimportant.   

The film begins in the studio of a local television newsroom in Pittsburgh.  There we are introduced to the central characters.  Other than this initial scene, and the brief scene that follows of our characters driving to Punxsutawney to cover Groundhog Day, the remainder of the film is set in this small town, home to the festival.   The lively festival itself - which elevates an earthy superstition about the weeks of winter weather that remain based on whether or not the groundhog “sees his shadow” on the day in question – is that typical county fair type of fun:  simple, unassuming, and a bit of tongue-in-cheek silliness.  This is small town America, and while plenty of fairly good-natured comedic jabs are placed at its inhabitants’ expense, and there are certainly some stock comic characters, by the end of the movie, we largely see Punxsutawney on a natural, human scale, from its own point of view.   That is, in the end, the film manages to neither condescend nor romanticize.   The town’s characters, to the extent they are developed, are taken in full.  Overall, they cease being an “other” to our urban visitors and are simply human beings in their own setting, with all of their virtues, vices, dreams, and disappointments. 

It is perhaps important to note a quarter century later that this is small town America prior to the dramatic increase in social pathology that we witness now - which is itself quite another story.  The film does not seem otherwise remarkably dated, or at least to me does not seem as distant as say 1968 cinema (Oliver!, The Lion in Winter, The Odd Couple, 2001: A Space Odyssey, Funny Girl) was to 1993.  The most obvious difference to today is the absence of the internet and the smartphone.  The mechanical/electrical clock radio was already a bit dated, but might easily have been found in a bed and breakfast not updating its electronics every few years.  The other difference worth pointing out is the relative cultural importance of local weathermen.  Nowadays, of course, one has weather apps on phones, weather sites on the internet, etc.  There was a time, however, when one relied on newspapers for forecasts, and then radio and television.  Cable outlets such as CNN, CNN’s Headline News, and even The Weather Channel were around by ’93 but to see the local forecast prior to the morning paper, the most reliable source was often the local newscast, even if cable had chipped away at this monopoly somewhat by then.  Plainly stated, the average citizen had a much greater likelihood of knowing who his local station TV weathermen were then than now.

The central character of our story is this particular Pittsburgh station weatherman, the miserable Phil Connors, played by Murray.  His character when we are introduced to him is a cynical misanthrope, a self-centered snob possessing an acidic wit, a snarky sense of humor.  The story of Groundhog Day is the story of his transformation.  A bit like with Dickens’ Scrooge in A Christmas Carol, this is a story of moral redemption.  It is his (not necessarily religious, but see below) Road to Damascus.  To stretch this last metaphor, if the repeating day is him becoming blinded by the light, it is through Rita that we see the scales fall from his eyes.

The opening scene shows Connors in studio giving his last weather report before heading out to Punxsutawney.  The opening line: “Somebody asked me today, ‘Phil, if you could be anywhere in the world, where would you like to be?’”  (Remember this line, dear readers).  He goes on to name the locale with the nation’s winter high temperature for the day.  In addition to some other jokes, he here predicts that the upcoming storm will likely bypass Pittsburgh.  Once the camera cuts, he’s all elbows and barbs with his fellow newsroom anchors and crew.  Here we meet briefly Larry the cameraman (Chris Elliott) and Phil’s new producer Rita (Andie MacDowell). 

The next scene shows the three in the station’s van heading to location.  In these first two scenes we are introduced to Connors’ aforementioned misanthropy in general and disdain for Punxsutawney and its festival specifically.  Rita’s response:  “I think it’s a nice story…people like it.”  Phil:  “People like blood sausage too.  People are morons.”  On arrival at the hotel, Phil notes that he cannot stay at the “fleabag” where he’s been miserable on prior trips to cover the groundhog and she notes that she’s already arranged for him to stay at a different location, a bed and breakfast.   Phil, pleasantly surprised, replies:  “I think this is one of the traits of a really good producer.  Keep the talent happy.”

The next morning is Groundhog Day.  A cock crows and the clock-radio alarm in Phil’s room flips from 5:59 to 6:00.  Cue the Sonny & Cher song “I Got You Babe.”   As Phil prepares for the day, we hear the local radio DJ’s raucous banter, there is a brief scene of him interacting with a fellow guest at the top of the stairwell, and with the Inn’s proprietress, then he’s off to cover the groundhog, Punxsutawney Phil.  (Surely the sharing of a name is not a coincidence).  On his route, he passes a single elderly beggar and then runs into Ned Ryerson, the obnoxious insurance salesman who recognizes him from high school.  After stepping in an icy pothole to escape Ned, he’s at Gobbler’s Knob, the site of the festival.  He does a sarcastic minimum for the broadcast and then the three are back in the van headed home to Pittsburgh.  Except Phil’s forecast was wrong, the blizzard hits.  The road is blocked off, and a frigid Phil in shirtsleeves exits the van to confront the state trooper in disbelief of reality: “I make the weather,” he bellows through chattering teeth.  We see him using a pay phone, speaking to the operator about the long distance lines being down:  “Don’t you have some kind of a line that you keep open for emergencies, or for celebrities?  I’m both.  I’m a celebrity in an emergency.”  Next we cut to the three back in Punxsutawney at a hotel bar.  More snide Phil in general, including responding to a gracious Rita, culminating in: “I think I’m going to go back to my room, take a hot shower, and maybe read…some Hustler or something.”  Naturally at the end of this miserable day there is no hot water in the shower. 

It’s 6:00 a.m. again on the clock radio alarm.  The radio comes on – again to “I Got You Babe,” and the DJ’s.  Phil assumes they are mistakenly playing yesterday’s tape.  He looks out the window to see no fresh snow.  A series of these déjà vu moments occur over two days as Groundhog Day continues to repeat itself.  He insists Rita meet him at the diner.  Explaining his situation, he demands she do something about it.  “What do you want me to do,” she asks.  Phil snarls “I don’t know.  You’re a producer.  Come up with something.”  Rita responds “You want my advice?  I think you should get your head examined if you want me to believe a stupid story like that, Phil.”  He goes to see a local neurologist played by Ramis who suggests he see a psychiatrist, who in turn - overwhelmed - suggests he come back “tomorrow.”

“The Ring of Gyges” is a mythical ancient artifact best known from Plato’s Republic where it serves a role as a thought experiment in a discussion about justice or morality.  The ring renders one invisible.  Would the owner of such a ring really act justly if there were no possibility of being caught in injustice?  If there are no possible consequences is there any reason not to cheat, steal, etc.? 

We next see Phil drinking late at night with two locals at a bowling alley bar.  First, a glimpse into Phil’s lightly worn, thoroughly modern, default hedonism:

“I was in the Virgin Islands once.  I met a girl.  We ate lobster; drank piña coladas.  At sunset we made love like sea otters.  That was a pretty good day.  Why couldn’t I get that day, over and over, and over?” 

Next Phil and his drinking companions leave to drive home.  The other two are far too drunk to stand, let alone drive, so Phil drives.  Here he realizes that with the repeating day there may be no consequences for his actions - it’s his ring of Gyges, so to speak.  Why follow all of life’s rules, anyway?  He rams into a mailbox for no reason, leads the pursuing police on a chase down railroad tracks, narrowly avoids a head on collision with a train, and ultimately, after crashing into a giant cutout of the groundhog, proceeds to place an order with the arresting officer for cheeseburgers.   He’s thrown in jail but still wakes up at 6:00 a.m. to “I Got You Babe.”

At first, he is elated with what he has just gotten away with.  He is a free man.  There are no officers looking for him. We proceed to see him punch Ned Ryerson in the nose, stuff himself with food, smoke cigarettes, and learn to time the theft of a bag of cash from an armored truck due to the inattention of the two dimwitted elderly drivers.    Rita, at the disgust of seeing his gluttony quotes lines from Walter Scott’s “The Lay of the Last Minstrel” about “the wretch concentred all in self…”

Phil next proceeds to seduce local women through trickery and deceit.  He asks the first of these women questions about herself and comes back the next day to pretend to know her from high school.  His success with this line of conquest leads him ultimately to focus his attentions on Rita, who has become, or perhaps always was, the true object of his desire.  He learns all about her, her favorite drink, the toast she drinks to, her undergraduate major in 19^th century French poetry, her taste in food, her career aspirations, what she thinks she’s looking for in a man,¹ her desire for a family.  He slowly plans everything, day after day.  He memorizes some verse en francais.  He comes close - but he fails.  She ultimately sees through his ruse.  Her rejection line “You love me? You don’t even know me” echoes the Ray Charles song they had danced to earlier in the gazebo as the snow fell (“You Don’t Know Me”).  Now each day of repeated attempts finds him failing earlier and earlier in his attempt to seduce Rita.  He, indeed, fails completely.

Like an addict, Phil has hit rock bottom.    Despondent, he sits around drinking, depressed, memorizing Jeopardy answers on the parlor’s television.  Ultimately, he attempts to end the repeating day by ending his life, at first also along with the groundhog’s.  He steals a truck containing Phil the Groundhog and the two Phils - the two weather predictors - drive off a cliff while Rita, Larry, Punxsutawney police officers, and town officials look on.  He tries eventually every method of suicide imaginable, but he keeps waking up at 6:00 am on Groundhog Day to “I Got You Babe.” 

In the pivotal scene, or really three scenes, Phil is first in the diner again with Rita.  Rita:  “I’m sorry, what was that again?”  Phil:  “I am a god.”  Rita:  “You’re god?”  Phil:  “I’m a god, I’m not the God.  I don’t think.”  He explains that, no he just didn’t survive a car wreck but a long list of every possible means of dying – and every morning he wakes up alive and without injury.  “I am an immortal.”  She asks “Why are you telling me this?” He replies “Because I want you to believe in me.”  She doesn’t, of course: “You’re not a god.  You can take my word for it.  This is twelve years of Catholic school talking.”   “How do you know?” he rejoins.  He then proceeds to demonstrate his omniscience.  He walks throughout the diner and introduces all of the employees and patrons to Rita, giving details of their lives, childhoods, and aspirations.  They, of course, do not know him.  “Is this some kind of trick?” she asks.  Phil:  “Well maybe the real God uses tricks.  You know, maybe he’s not omnipotent he’s just been around so long he knows everything.”  Phil then predicts the future – a waiter dropping a tray of dishes.  In hushed tones she sits down and asks if he knows all about her.  He does, of course.  He knows her childhood, her cherished memories, her dreams, her genuine goodness, and that when she stands in the snow she “looks like an angel.”  “How are you doing this” she asks.  He again tells her about his repeating day.   For a last demonstration, he writes down the precise words that Larry will say when he enters the diner to get them back in the van and on the road to beat the storm.  In contrast to his much earlier demand that she, as his producer, “come up with something,” he now is imploring her:  “Please believe me.  You’ve got to believe me.” 

Next, they’re walking outside down the sidewalk.  Rita:  “Maybe it really is happening.  I mean, how else could you know so much?”  Phil replies “Well there is no way, I’m not that smart.”  Rita:  “Maybe I should spend the rest of the day with you.  As an objective witness, just to see what happens.” 

In the last of these pivotal scenes Phil and Rita are now sitting on top of his made bed flipping playing cards into a top hat.  “Be the hat” he encourages her, in a reference to a well-known line from an earlier Ramis-Murray comic hit.  He has had hours of practice with this trick, he explains.  He then tells Rita that the worst part is that “Tomorrow you will have forgotten all about this and you’ll treat me like a jerk again.”  “No!” she objects.  Phil:  “That’s alright, I am a jerk.”  Whether simply to cheer him up - or not, she seems sincere - she tells him “Sometimes I wish I had a thousand lifetimes.  I don’t know Phil, maybe it’s not a curse.  It just depends how you look at it.” Later, while trying to wait for the morning with him, she struggles not to drift off to sleep and murmurs “what were you saying?”  Phil, reading from an old poetry anthology, says “I think the last thing you heard was ‘Only God Can Make a Tree’” (from a poem about the superiority of nature to human art).  Phil now gazing at the sleeping Rita:

“What I wanted to say was I think you’re the kindest, sweetest, prettiest person I’ve ever met in my life.  I’ve never seen anyone that’s nicer to people than you are.  And the first time I saw you something happened to me I never told you about.  I knew that I wanted to hold you as hard as I could.  I don’t deserve someone like you.  But if I ever could, I swear that I would love you for the rest of my life.”

It’s 6:00 a.m. again on the clock radio.  “I Got You Babe” again.  Henceforth, we witness the transformation of Phil.  First, he stops to give the elderly panhandler a little cash.  He brings coffee and pastries to Rita and Larry for the Groundhog shoot – knowing their orders, naturally.  He helps Larry with the equipment. 

He begins to appreciate art and music.  We see him sitting alone at the diner’s lunch counter reading books as Mozart plays.  He decides to take piano lessons, which recur over the repeated days.  He’s friendly to the man in the Inn on the staircase who greets him each morning and quotes poetry in his reply.² He learns to ice sculpt.  He is no longer only spending his hours getting good at flipping cards into a hat.  Whereas before he had memorized 19^th century French poetry as a means to an end – seducing Rita – he now is doing these things for their own sake.  We might say that we get a glimpse here of not just the good but also of the beautiful, the noble. 

Phil next attempts to save the elderly beggar.  He takes him to the hospital where he dies.  Phil, disturbed, asks “what did he die of?”  The nurse: “sometimes people just die.”  Phil:  “not today.”  The next day he tries to nurse the man to health himself by feeding him at the diner.  Phil fails repeatedly, confirming in his failure both the limits of life and that he is not, in fact, divine.  The last time we see him with the man, Phil calls him “Dad” and attempts CPR as the man lies lifeless in a dark alley.  As the old man lies dead, and Phil ceases his efforts, the scene ends as Phil fixes his gaze upwards on the dark night sky. 

Phil Connors has become a kind and good-hearted man, a man of integrity and character, a contemplative man, and a man, as well, of some genuine talent.  His humor remains but it is now a good humor.  This transformation culminates in one last day which starts with his on-air speech at the festival, worth quoting in its entirety: 

“When Chekhov saw the long winter, he saw a winter bleak, and dark, and bereft of hope.  Yet we know that winter is just another step in the cycle of life.  But standing here among the people of Punxsutawney, and basking in the warmth of their hearths and hearts, I couldn’t imagine a better fate than a long and lustrous winter.   From Punxsutawney, it’s Phil Connors, so long.”

Surprised, impressed, and intrigued by this Phil, Rita asks if he’d like to get a cup of coffee.  He asks for a “raincheck” as he has errands he needs to run.  “Errands, what errands?” asks a perplexed Rita. 

                After leaving Gobbler’s Knob Phil runs to catch a boy falling from a tree.  The boy runs off.  “You little brat, you have never thanked me!” he shouts (while remaining still an imperfect human being, we might note).  No one sees him save the boy, and the boy indeed does not thank him (recall the ring of Gyges, and consider its mirror image).  Phil next appears with jack and tire to change a flat tire for a carload of elderly women – instantly after the flat occurs.  In a restaurant he then performs the Heimlich maneuver on a choking Buster, the emcee of the Groundhog Day festivities. 

                That night, at the Groundhog Day party at the hotel, Rita and Larry walk in to find Phil featured on the piano with the jazz band on stage.  Everyone there knows him and seems to love him.  As Rita dances with him briefly, he is thanked by many of the locals for his various deeds.  Then, in a scene of Girardian mimesis, there is a “bachelor auction” for charity where several townswomen bid up Phil (who doesn’t volunteer, but goes along with the fun).  Rita, now attracted to this new Phil, empties her wallet to win her prize.  Outside, he sculpts a bust of her in frozen snow.  She’s moved, flattered, and astonished by his skill.  His reply:  “No matter what happens tomorrow or for the rest of my life I’m happy now, because I love you.”  Rita:  “I think I’m happy too.”

                   She wakes up next to him in his room, both of them clothed, and she notes that he had fallen fast asleep the night before (i.e. without sex).  The same song – “I Got You Babe” - comes on the radio – but it’s actually a new day, the cycle is over.  They go outside to see the fresh snow.  Phil:  “It’s so beautiful.  Let’s live here… [pregnant pause]…we’ll rent to start.”  The film ends as they walk alone down the street while in the background we hear the old standard “Almost Like Being in Love.” 

*             *             *

                What to make of this quirky and contemplative comedy that packs so much, so tightly, into 101 minutes?  As I state above, it is principally the story of the moral redemption of Phil Connors.  It is worth looking at this more closely and beginning with the obvious features.

 

In the beginning Phil was a miserable “jerk” but not a sociopath.  Even when he begins to break society’s rules he is not really a violent criminal.  What he does to seduce the women is clearly and unequivocally wrong, but not physically violent. 

Unlike what has been the case for many humans throughout history, in Punxsutawney 1993 it goes without saying that Phil is in no physical danger.  He’s a free man who does not lack for a roof over his head and for whom his next meal is not in doubt.   These basic conditions of safety and comfort are necessary, of course, but, as we are shown, not sufficient for a good life.  Phil has some ambition – he doesn’t want to stay at the station in Pittsburgh forever, for example – but what are his goals, his deepest dreams, and what informs them?  Does he know?  Is it just the unreflective hedonism he pines for in remembering his time in the Virgin Islands?  We might conclude that his unhappiness and shallowness are fully unmasked by the recurring day.  When he abandons all restraint we realize that he doesn’t gain any real freedom – he crashes into a mailbox, drives on the railroad tracks, eats 10,000 calories per meal, etc. – he just loses self-control.  The brief thrill of unpunished immoderate behavior cannot sustain him during the recurring day.  It certainly cannot be the basis for true happiness; rather, it serves to illustrate the difference between liberty and license. 

Unlike many films, action movies for example, Groundhog Day is not a story about physical or moral courage.  Phil is not saving the world from tyranny or putting himself in peril to fight corruption, etc.  The film is about what we might call regular, day-to-day morality, about human character, goodness, kindness, self-control, as well as about art, poetry and contemplating the human condition.   Whether fully intentionally or not, Groundhog Day in its treatment of morality and character presents what we might call a Classical view of human nature, and of the relation between virtue and happiness.   In the mouth of the Platonic Socrates, and most fully articulated in Aristotle’s Nicomachean Ethics, we find the argument that happiness (eudaimonia) comes from virtue (arete).  Virtue here can also mean excellence, or perhaps developed talent.  There are many virtues: justice, courage, wisdom, self-control, generosity, etc.  Eudaimonia is also translated as flourishing or well-being.  Happiness, then - human flourishing - comes from the virtues, which in turn are reflective of human nature, including our nature as political animals (or social beings), while allowing that circumstances change with place and time.  One can clearly see such a view of human virtue and happiness in the life of Phil before and after his transformation.   The original Phil, the jerk, the man filled with arrogant disdain for his fellow man, is forced to confront his own character day after day and is deeply unhappy, to the point of utter despair.  Even when he attempts to imitate the virtuous traits Rita tells him she is looking for in a man, he fails.  However, the Phil transformed through his love for Rita, and through her example, begins to genuinely act well, which is its own reward.  He not only treats others selflessly, with authentic kindness, empathy, and generosity, he also is drawn to poetry and art for their own sake.  By the end he has become truly happy - by becoming virtuous.  Here we should also contrast the first and last lines of the film:  "Phil, If you could be anywhere in the world, where would you like to be?...It's so beautiful.  Let's live here."  Through his love for Rita, and because of whom he has become through Rita, the place he most wants to be is in fact where he is, wintry western Pennsylvania, the place where he least wanted to be. 

By showing us this account of virtue and happiness, Groundhog Day makes a claim about the nature of Man.³  While this film certainly presents an American, egalitarian type of good man, the presentation of morality, of virtue and happiness, seems broader – i.e. it seems natural and universal rather than artificial or wholly contingent.  We might note also that Groundhog Day presents this view while avoiding “politics” in the sense of the controversial and partisan.  While a claim about human nature, about morality and human happiness, may imply something about politics, ultimately, any such implication is wisely left out.  There are no leaden speeches about the issues of the day. 

If the central feature of Groundhog Day is the moral transformation of Phil Connors, the driving force behind that transformation is his love for Rita - Eros, in its general and specific sense (if one will excuse again the Greek).  I will admit that when I first saw this film on its release in the theater I walked away thinking that it was trying to show here something like Freud’s concept of sublimation, namely that Phil’s lust for Rita becomes channeled into something higher – essentially the high reducible to the low.  Now, not only do I disagree that that theory adequately describes the human phenomenon in question, I also do not think this is what is happening in Groundhog Day.  Phil clearly falls in love with the three dimensional Rita, the entire woman, body and soul.  This replaces what might have been an initial cruder attraction, but is not reducible to it.  We are presented with a full vision of romantic love, of Eros, as a longing, as a driving force, but also as a beautiful and noble thing taken on its own.  In addition, while Groundhog Day’s main theme may be Phil’s transformation revealing to us human nature, virtue, and happiness, it is important to note that we first see these things in Rita.  Phil sees in her an example of human virtue.  She becomes the object of his affection, his beloved, due to her physical and moral loveliness.  The reverse occurs, as well, by the end of the film when his love for her is reciprocated due to his being the man he has become.    

Since Phil’s profound love for Rita is the driving force of his transformation, the central event of the film, it is important to contrast it to the common Romanticism - with a capital “R” - that one finds in many 19^th century novels, and some films old and new, and which has its roots in Rousseau.  (Romanticism, of course, is broader in its meaning than just how it treats romantic love; here, to stay on topic, I stick to that aspect).  This Romanticism presents a view of romantic love as an ennobling force with the potential to lift humans out of the banality of bourgeois existence.  Romantic love is elevated above all else in the world including “conventions” like marriage, which is why adultery is often the theme.⁴  In real life, however, adultery, rather than being ennobling, is typically just destructive, of not only marriage, but of families.  In Groundhog Day, Phil’s love for Rita is not set into a sphere unconnected to the rest of his moral life, but rather into its proper place.  We see this primarily because we see that the love is the source of him becoming a better person in a full and broader sense.  We also see a glimpse of this contrast with Romanticism when he takes his raincheck to run his errands.  Coffee with Rita, however deeply desired, will have to be postponed briefly to save the falling boy. 

It would be incomplete to discuss morality and romantic love in Groundhog Day without touching on its view of sexual morality.  While it is not a prudish film, and is contemporary (or at least sits halfway between 1968 and 2018) in its mores, Phil’s views of sex do change from beginning to end.  In the beginning, he is guilty of making some lecherous comments towards Rita which would be considered workplace harassment today, and, probably, then.  By the end, however, he would not make a joke about reading Hustler, or in fact read Hustler, not because he has become a prude, but because a) he would not want to make someone else uncomfortable by being offensively boorish, and b) because it would be bad for his soul.  And while Phil and Rita do fall asleep together in the same bed the last night of the recurring day, their love is not consummated.  One is left thinking that the overarching meaning of Groundhog Day implies something perhaps closer to a traditional view of sexual morality, but if so, it is implicit, and like with politics it is left for us to contemplate.

Since Groundhog Day is a story of moral redemption, it is only fitting to ask also what it says about religion, about the divine.  There are a few mentions and allusions, as I note in the summary above.  First, and most explicitly, there is Phil’s claim to divinity, proven false by his failure to save the old man.  Second, it is mentioned when Rita states that she has had twelve years of Catholic school.  Third, when Phil fails for the last time in his attempt at CPR, he unmistakably looks to heaven, sadly, but with understanding.  Fourth, we hear the name of God in the pivotal scene where Phil reads the line from the poem he has just read:  “Only God Can Make a Tree.”  I will also note that one does sense that Phil’s character in the beginning is entirely secular.  One is perhaps not surprised, given her accent, to learn that Rita was at least raised as a churchgoer.  So while there are only a few explicit mentions of religion, it is also not precluded.  The film and its main theme operate largely in the realm of the human, of society, of human nature and human character, rather than in the realm of the metaphysical or theological.  While doing so it leaves open the question - the possibility that if nature is the standard, the divine may be the ground of that nature, and hence of human morality.  However, Groundhog Day - perhaps wisely for us, in our times – does stick to this natural, human scale, and avoids becoming an explicitly religious film.  Like with partisan politics and sexual morality, any implications are left unsaid. 

What of the most prominent feature of Groundhog Day, the plot device itself, the recurring day?  This feature fades a bit when we look at the story it presents of Phil’s transformation.  Yet at the conclusion, it confronts us again, as indeed it must.   We are left wondering, is it just a fantastical poetic device for showing us Phil’s transformation, like an extended version of Scrooges’ dreams?  When trapped in it with his old self, it becomes like an eternal punishment, a mythological curse – Sisyphus and his stone, Prometheus, his liver, and the eagle.  Through Rita and his transformation, Phil escapes only when it becomes unnecessary for him to escape, when living with himself ceases to be a punishment.  If not simply a poetic device, did it really happen?  Is it a “natural” phenomenon - was it a psychotic break, a dream, an epiphany?  Or, is it something beyond nature?⁵ The realm of the moral inevitably points beyond itself, nature to metaphysics and theology, being to the ground of being. 

There is likely every possible interpretation, religious & otherwise, already written about the meaning of the repeating day - Catholic, Protestant, Jewish, Buddhist, Hindu, secular, multiple universes, etc.  The film, however - and to make the point again - leaves this unsaid.  In doing so, it leaves open this largest of questions, and, by leaving it open, Groundhog Day accomplishes two things.  First, it leaves the film accessible to all – it professes no specific creed.  Second, in pointing to this, but leaving it open to all, it also underscores the universality of the moral realm based on nature – which is the movie’s theme, ultimately, even if it points beyond it.⁶  

                In the poem "Trees," from which Phil quotes the one line in the pivotal scene, and which I reproduce below, human art is presented as hopelessly inferior to nature.  We might note that this film attempts to reveal to us human nature through art.  Perhaps the reference to this poem is an acknowledgment of humility, an acknowledgment of the limited ability of human art to give a fully adequate account of nature.   Even if this is necessarily so, even if Groundhog Day is at best a humble attempt - a mere sketch, as it were - we its recurring audience can rightly conclude that Ramis and Murray do succeed  - on a small scale, in small town America, the type of place where adolescents full of wanderlust might complain that “nothing much happens” – in presenting to us a broad view of human nature, of human goodness, mercy, and love, of virtue and human excellence, of the meaning of human happiness, and of the deepest longings of a man’s soul.  What is all the more remarkable is that they do so at a lively clip and with a light heart – they do so while laughing all the way.

 

Trees

I think that I shall never see

A poem lovely as a tree,

A tree whose hungry mouth is prest

Against the sweet earth’s flowing breast;

A tree that looks at God all day,

And lifts her leafy arms to pray;

A tree that may in summer wear

A nest of robins in her hair;

Upon whose bosom snow has lain;

Who intimately lives with rain.

Poems are made by fools like me,

But only God can make a tree.

-          Joyce Kilmer

Notes   

1.       1) Rita’s list of traits she is looking for in a man:  humble, intelligent, supportive, funny, romantic, courageous, physically attractive without vanity, kind, sensitive, gentle, unafraid to cry in front of her, likes animals and children (and doesn’t mind changing “poopy” diapers), plays an instrument, and loves his mother.  It’s a long list.  Of interest, Phil comes closer to what she thinks she wants after his transformation than when he tries to be what she wants in order to seduce her.  In the end, he’s still probably not the perfect image of a man she thought she desired; he’s instead a virtuous version of Phil Connors.  There is great variation in human nature, after all, even if that variation has natural limits.

2.       2) “Winter slumbering in the open air, Wears on his smiling face a dream of Spring!”  A nice sentiment delivered cheerfully, but worth noting that it is from the melancholy Coleridge poem “Work without Hope.”

3.       3) It would be interesting at greater length to contrast that claim with that of other films from the same era.  For example, and briefly, 1) Joe vs. the Volcano (civilization is unnatural and puts Man in chains) 2) Fight Club (nihilistic view of Man, which can be rescued through sublimation of pure Romantic Love) 3) The English Patient (typical Romantic 19th century novel type view that life can have an elevated meaning though pursuit of pure passion and Romantic Love, silly conventions like marriage and adultery be damned).

  

4.       4) I am reminded here of a story Allan Bloom tells about teaching a class with the Nobel Prize winning novelist Saul Bellow: “Once in class I said, with a rhetorical flourish, that all nineteenth-century novels were about adultery. A student objected that she knew some which were not. My co-teacher, Saul Bellow, interjected, ‘Well, of course, you can have a circus without elephants.’ And that’s about it.”  (Allan Bloom, Love and Friendship p. 209).  I was also reminded of this story when the “Ringling Bros. and Barnum & Bailey Circus” announced in 2015, under pressure and after lawsuits from animal rights groups, that it would stop using elephants in its shows.  The last elephants performed May 1, 2016.  The circus folded and ceased operations in May of 2017 after 146 years in business.

5.       5) Is it perhaps a stretch to note that the closing song, “Almost Like Being In Love,” is originally sung by the character Tommy in the musical Brigadoon after he falls in love with Fiona who is from the magical town in Scotland he and his friend have stumbled upon that only exists for one day each hundred years?

6.       6) Consider, from the standpoint of one revealed religion, the natural justice written into men’s hearts, men for whom the revelation is unavailable.  Deuteronomy 4:6:  “Keep therefore and do them; for this is your wisdom and your understanding in the sight of the nations, which shall hear all these statutes, and say, ‘Surely this great nation is a wise and understanding people.’”

Epstein on Natural Law, Ancient and Modern

A few brief thoughts I may return to later, time and study permitting.

One of the many wonderful things about our modern life is how quickly and easily accessible things are which would have been either inaccessible or time-consuming to access just a few brief years ago.  I recently stumbled upon a couple of Richard Epstein talks recorded on youtube.   They virtually allow one to attend those talks from the past – from any time and place.  How remarkable, if you pause for a moment to not take the development for granted.

This one here, in particular, is well worth watching: https://www.youtube.com/watch?v=R_ge4tYI8Vk

It is entitled “Natural Law in Ancient and Modern Guise.”  It is from 2010, and runs about one hour, with extra time for questions/answers. 

Epstein, a prolific academic writer and thinker, speaks, as always, in complete paragraphs, quickly and effortlessly.  He clearly knows his topics backwards, forwards, and sideways.  Even if one is inclined to disagree with him altogether, or in part, it is always most challenging and rewarding to hear the opposite side of the argument cogently argued.

For those inclined to agree, watch it twice. 

Or thrice.

I find that many who think well and deeply about political theory and philosophy are relatively uninformed about, or ignore altogether, economics and the revolution in economic life over the last quarter millennium.  Economists, however, often have a naïve or diminished view – or even an unmanly contempt for - the political and cultural structure that necessarily provides the foundation for a free and peaceful economic life.  

Epstein falls into neither camp.  He has a commanding grasp of both economic theory and of political philosophy.  He comes at all this, somewhat uniquely, from the standpoint of the law, and as a law professor.  As a non-lawyer I find this intriguing.  When he talks about economics and political theory, he typically thinks about not just the theory and broad “constitutional” questions (meant here not to only refer to the US constitution) but also the very specific legal issues that arise.  His description of Roman law and the pre-Thomistic “natural law” is fascinating.   He ties this to Anglo-American law, written and unwritten.

(There is also an insightful question and answer exchange around the question of natural right and natural law.  One is reminded that Leo Strauss pointed out that the ancient philosophers contrasted “nature” and “law/custom[nomos].”  Justinian Roman law, one assumes, could think about laws which are natural [not customary] since the Empire had created a universal political and legal system, a situation distinct from that of the ancient city).

Epstein's strong preference is for the classical liberal position, in politics, in law, and in economics.  He explains how these are intrinsically linked.

The concluding remark is this:  “Essentially the lesson is, unless you can master the ancient conceptions of natural law, you will never be able to do modern public policy well.”  How he gets there is an hour well spent.

Epstein also has a “new” book out (2014) that is on my list to read.  “The Classical Liberal Constitution: The Uncertain Quest for Limited Government”

Amazon link:  http://www.amazon.com/The-Classical-Liberal-Constitution-Government/dp/0674724895

He gives another fine talk on that book and on Hayek here:  https://www.youtube.com/watch?v=DhqXIc5CEpU

The Best Defense is to Take Offense?

This week Dr. Bob Wachter wrote a blog post that is the first attempt I am aware of by a member of the ABIM leadership to defend the organization against the now widespread allegations of egregious waste and derelict stewardship.  It can be read here:  "The ABIM Controversy: Where the Critics are Right, Where They’re Wrong, and Why I Feel the Need to Speak Out."

He starts his piece in a pique of moral indignation: 

With the help of social media and a journalist who has turned this matter into a cause célèbre with an unfortunate mixture of half-truths and innuendo, the critics have managed to control the debate, and people who believe in the values of the Board have been cowed into silence. It feels vaguely McCarthyish, and there comes a time when silence is immoral. This feels like such a time.

Joseph McCarthy was of course the U.S. Senator interrogating possible communists.  However, an investigative reporter, an electrophysiologist blogger, et al. do not sit in the seat of power.  No, it is the ABIM that holds great power over the lives and careers of 200,000 physicians in this country.  Indeed, if one must use a 20^th century Republican politician’s name as an adjective appropriately in this case to describe a person who holds a position of great responsibility and power and believes himself to be persecuted against all evidence, the correct word is:  Nixonian, and it applies not to his detractors but to the good doctor himself.

Now, there are many aspects of this ABIM controversy.  They include, but are not limited to 1) the issue of certification, re-certification, MOC, etc. 2) the existence of, reason for, politics of, and funding of the ABIM Foundation, and 3) the financial details.

In the interest of space and time, and since it is covered so exhaustively elsewhere, I will leave aside #1 and #2 for now. 

Regarding number 3:  After reading Dr. Wachter’s post I have re-watched Dr. Cutler’s debate with Dr. Baron from December of 2014 and re-read Dr. Westby Fisher’s posts and Kurt Eichenwald’s Newsweek stories.  What does Dr. Wachter have to say about the allegations of egregious waste, lavish spending, exorbitant salaries, and derelict stewardship of trust and resources?  Does he dispute the facts?  If not, does he offer an explanation that addresses the specifics? 

Let’s looks at his piece.  Against the charge that “The Board is All About the Money” he writes: 

As Board members, we constantly struggled with balancing our fiduciary responsibility to the organization (including to pay the salaries and the costs of doing the Board’s current work and innovating) with the burden to the diplomates. ABIM’s MOC process currently costs physicians about $200-$400 per year (the low end for the internal medicine certificate only; the higher range is for those maintaining multiple certificates, like IM/cardiology/interventional cardiology). These costs are consistent with the fees of other ABMS boards. The argument that this represents an impossible expense to the vast majority of practicing physicians is hogwash.

That’s it.  They “struggled,” and the cost is not that much per person anyway, so “shut up” (leave aside for the moment those that dispute the true cost). [Edit 7/7/15 I will add that it should go without saying that when the Board authorizes wasteful spending it does neither its fiduciary duty to the organization nor its duty to the Diplomates]

His section regarding salaries and the Condo is equally pithy.  He only addresses the CEO’s salary, for example.  Let’s ignore that for now and assume the CEO deserves every penny. If I round up to one million for his salary/benefits, we are still left with salaries/benefits for the ABIM and its Foundation of $29,000,000/year!  This is to run what should essentially be a testing and record-keeping company, if a large and sophisticated one at that.  And again, this is not the budget, just the payroll.  What about the assistant to the President who Dr. Cutler pointed out made $689,000 in 2011?  Do we finally learn her job description or why she was worth this from Dr. Wachter?  He was on the Board of Directors at the time and presumably voted on the budget.  No, it’s not mentioned.  How about the two researchers on the benefits of MOC who made $450,000/year?  Are the salaries mentioned?  Is the embarrassing conflict of interest mentioned?  No, nothing.  Even the “Senior Vice President of Communications” reportedly was compensated $293,000 in 2013.  The point is it takes a lot of employees earning large salaries to reach a sum of $29,000,000/year.   I should point out that these are not my facts.  I am simply repeating what I have seen and read reported.  No one from the ABIM has substantively disputed the numbers, nor defended them.  Despite the length of his post, Dr. Wachter also simply ignores them.

Regarding the Condo he essentially admits that it looks bad, but was really “designed to be revenue neutral” compared to hotel room costs for consultants.  This is thin gruel, if not outright laughable.  First, the only reason to buy rather than rent is to save money, not break even; and if looking to save money Dr. Cutler points out less expensive units practically across the street.  He relates having been told that the Condo the ABIM did purchase was the most expensive real estate in Philadelphia per square foot!  One comes to the inevitable conclusion that thrift was not exactly a concern at the ABIM in those days.  With the caveat that any analysis of the finances of the condo vs. hotel rooms obviously leaves aside the fact that the condo would not suffice if more than three rooms were needed at a time, let’s take a quick look at the numbers.  Traditionally, financial theory in retirement has suggested that 4%/year may be spent from a well-invested nest egg without affecting the long-term real principal.  Some argue that this is too high given today’s interest rates and equity valuations.  So, let’s be very conservative and take 2.3 million invested in index funds and treasuries, and spend 2.5%/year on hotel rooms.  This comes to $57,500/year.  The condo’s expenses (not taking into account depreciation) were roughly $42,000/year (per Dr. Wes’ post).  So we have at least $100,000/year in hotel costs that the condo represents if “revenue neutral.”  I will let this speak for itself.

As we see, then, Dr. Wachter does not seriously address any of the allegations of financial waste that have come to light in the last seven to eight months.  On salaries, Four Seasons meetings, etc. he simply ignores most of the points made by Dr. Cutler in December, let alone the mountain of additional information that has surfaced since.  In the end, one can only assume that he neither disputes the facts of the allegations nor defends the ABIM’s actions (assuming the facts correct) for a simple reason:  There is no credible defense.

In his penultimate paragraph he states:

I further believe that this process must be crafted by members of the profession itself – and if we abrogate that responsibility, others will fill the void.

Well, to that a great chorus of readers cries out:  “If the unelected, unaccountable, unrepresentative, monopolistic, and profligate ABIM is self-government, then give me George III.”

He ends with a martial metaphor:

“Throw the bums out!” can feel like progress. But, as the Arab Spring protesters have learned, sometimes it’s relatively easy to tear down institutions. Rebuilding them is much harder.

This is hyperbole, or course, but I will indulge it.  It is true that more often than not bloody political revolutions and coups do not turn out well.  There is a document, 239 years old tomorrow, that addresses this fact:

Prudence, indeed, will dictate that Governments long established should not be changed for light and transient causes; and accordingly all experience hath shewn, that mankind are more disposed to suffer, while evils are sufferable, than to right themselves by abolishing the forms to which they are accustomed. But when a long train of abuses and usurpations, pursuing invariably the same Object evinces a design to reduce them under absolute Despotism, it is their right, it is their duty, to throw off such Government, and to provide new Guards for their future security.

Busy internists are not your typical torch and pitchfork crowd.  Prudence is their virtue. 

I do not know how this controversy will ultimately end, but I do know that Dr. Wachter’s post is not an apology, not an adequate defense, and not a way forward.

Why the ACP needs to comment on the ABIM scandal

It has been now over four months since Dr. Wes Fisher’s post on the ABIM luxury townhouse and since Dr. Charles Cutler’s debate with Richard Baron: events which began the exposure of the details of the ABIM financial scandal. 

It has now been roughly two and six weeks respectively since Kurt Eichenwald’s Newsweek articles on the ABIM and its financial scandal.

While they have commented on the maintenance of certification process at the ABIM, the American College of  Physicians - which regards itself as the organization for internal medicine - has yet to issue a statement regarding the ABIM financial scandal or its details. On the ACP advocate blog  (authored by Bob Doherty, ACP’s head lobbyist) over this period of time, one can read about not just the recent SGR saga, but also handguns, and on his twitter feed he shared a story about the POTUS and the new Surgeon General addressing the “health effects of climate change.”  However, nowhere is there any coverage of this huge story, a scandal that directly affects internists.

So:  Handguns and Global Warming from the ACP, but not a word on these very serious allegations of fiscal impropriety at the certifying board.

How can this be? 

Some suggest that the ACP has a conflict of interest in that they profit from test prep materials and courses. 

Some also suggest that there is a revolving door, of sorts, between many of these organizations.  A case in point:  the former longtime CEO of ABIM, Christine Cassel, has listed on her bio at the National Quality Forum that she is a Master of ACP and former President of ACP.  So far as I know, no one at ACP has publicly questioned her leadership while at the ABIM.  

For the moment, however, put aside these thoughts.  Moral courage (to overstate the ethical requirements in this case, certainly) is not doing the right thing when it easy and profitable.  Quite the contrary, courage is doing what is right when it is difficult, or otherwise against one’s personal interests.

The ACP should do what is right on behalf of its current and potential members and publicly express concern about the allegations of financial mismanagement at the ABIM. At some point, the failure to condemn is to condone.  That point, if not yet behind us, will be past soon. 

In the end, can a voluntary organization afford not to speak on behalf of its dues-paying members when the cause is right?

References:

Dr. Wes Blog:  http://drwes.blogspot.com/

Newsweek articles:  

http://www.newsweek.com/2015/03/27/ugly-civil-war-american-medicine-312662.html

http://www.newsweek.com/certified-medical-controversy-320495

The Board of Directors at the ABIM: Will they defend their record? Or were they apathetic, incompetent, or deceived?

For readers that would like more detail, I will refer to my prior post, as well as to Dr. Westby Fisher’s comprehensive coverage of the ABIM scandal, on his blog: http://drwes.blogspot.com/

Today, in Newsweek, Kurt Eichenwald wrote a piece, that updates this scandal on a mainstream media site. Link here: http://www.newsweek.com/ugly-civil-war-american-medicine-312662

With gems such as: “…the ABIM went from being a genial organization…to something more akin to a protection racket.” And, best of all: “the ABIM Foundation that does…well, it’s not quite clear what it does. Its website read like a lot of mumbo-jumbo.”

So, we have here a protection racket with its spin-off “mumbo-jumbo” cousin. For those counting, that’s mumbo-jumbo with a $30,000,000/year payroll (not total budget, just salaries and benefits between the two organizations! [source: tax records as documented by Charles Kroll]).

All of this brings me to this point. Some like to imply that blame for this scandal should be placed mainly on the prior president/CEO (the beleaguered Christine Cassel, currently the head of the National Quality Forum, who was forced to resign last year from high-paying corporate boards due to serious conflicts of interest: http://www.propublica.org/article/payments-to-ceo-raise-new-conflicts-at-top-health-quality-group).

However, sitting on the board of any organization is a serious endeavor that deserves to be treated as such. It is not only a CV-builder and not only a place to nurture relationships. Unless they can prove that they were actively deceived by Dr. Cassel, et al., the board members past and present are ultimately responsible for what the ABIM has become. The current names and bios of board members are readily available at the ABIM and ABIM foundation websites.

These men and women who have served on the board of the ABIM over the last ten to fifteen years have only two possible primary responses to this scandal and their involvement with it:

1) Defend the organization as currently constituted.

No human institution is perfect, of course. An adequate defense, however, would recognize that while there will always be minor shortcomings a clear and convincing argument is necessary regarding both the charges of impropriety (luxury townhouse, etc.) and how it is that the ABIM needs a thirty million dollar payroll. It is not easy to imagine such an argument being a cogent one.

2) Demonstrate that he or she actively voted against or otherwise fought against these developments.


Other than 1 or 2, the only other possible explanations for the board members' work at ABIM are the ones I list in my title: apathy, incompetence, or having been deceived by the leadership.

Which is it?