Saturday, December 19, 2020

My 2015 post on why Trump was a sign of a healthy democracy

I'm on the way to writing about what I think should be Biden's #2 priority (#1 is undoing Trump's executive orders). Three previous in this series include: 

  1. How I think about the Trump voter (and America)
  2. What is middle class and why can't half of American voters get there?
  3. Biden's lost agenda
This fourth post is about something I wrote in 2015. Back then I thought Trump was a bad joke. I thought that American politics was a compromise between corporations, powerful (wealthy) individuals, and the voting masses. Clearly corporations and the wealthy would prefer many GOP candidates over Trump, and the masses alone would not be enough.

Yay masses.

Now, amidst the smoldering wreckage, I'm going to quote from that old misguided post (emphases added): 

Donald Trump is a sign of a healthy democracy. Really.

... I’m a fan because Trump appears to be channeling the most important cohort in the modern world — people who are not going to complete the advanced academic track we call college. Canada has the world’s highest “college” graduation rate at 55.8%, but that number is heavily biased by programs that can resemble the senior year of American High School (in Quebec, CEGEP, like mine). If we adjust for that bias, and recognizing that nobody does better than Canada, it’s plausible, even likely, that no more than half of the population of the industrialized world is going to complete the minimum requirements for the “knowledge work” and “creative work” that dominates the modern economy.

... This [never-college] cohort, about 40% of the human race, has experienced at least 40 years of declining income and shrinking employment opportunities. We no longer employ millions of clerks to file papers, or harvest crops, or dig ditches, or fill gas tanks or even assemble cars. That work has gone, some to other countries but most to automation. Those jobs aren’t coming back.

The future for about half of all Americans, and all humans, looks grim. When Trump talks to his white audience about immigrants taking jobs and betrayal by the elite he is starting a conversation we need to have. 

It doesn’t matter that Trump is a buffoon, or that restricting immigration won’t make any difference. It matters that the conversation is starting. After all, how far do you think anyone would get telling 40% of America that there is no place for them in current order because they’re not “smart” enough?

Yeah, not very far at all.

This is how democracy deals with hard conversations. It begins with yelling and ranting and blowhards. Eventually the conversation mutates. Painful thoughts become less painful. Facts are slowly accepted. Solutions begin to emerge.

Donald Trump is good for democracy, good for America, and good for the world.
"Good for democracy" except, of course, the white non-college masses spoke clearly back in 2016. An actual "President Trump" was unthinkable, but it happened. I do not underestimate him now.

So that part of the post did not hold up so well. But I stand by the part about making the never-college 40-50% of Americans a political focus. More on that when I write the fifth post in this series.

See also

Monitoring the patient with chronic kidney disease -- my ABFM QI project criteria

Every three years I have to do a quality improvement project to maintain my family medicine board status.  This year I decided to focus on my patients with moderate chronic kidney disease. I have access to a report that identifies the patients of interest so all I need to do for the project is upgrade their care.

To do that I had to put together a list of things to do by reading the short "pocket card" version of the VA/DoD care guidelines (I'm too lazy to read the entire long thing). I then ran it past a friend who is a leading research nephrologist to comment on which of the guideline actions were really valuable.

I liked the result so much I'll share it here. The numbered items are what I took from the guidelines, the comments in () are his corrections, the comments in [] are my later thoughts. I think it's most interesting to read with both, I added emphases: 

As of Dec 2020:

1.       Measure urine alb/cr ratio yearly (sure in people with diabetes not on ace/arb)

2.       Measure Cr yearly (ok- not great evidence) [U/A, micro albumin, Iron]

3.       ACE/ARB for all but not both (if htn and/or microalbuminuria – or chf) [so implies measure for microalbuminuria along with yearly Cr]

4.       Oral iron therapy (if iron deficient, or starting epo) [so, contra guideline, not routinely, but implies check iron yearly?]

5.       If Hgb < 10 consult for erythropoietin (I’d wait till < 9 – no evidence for greater)

6.       DM

a.       Evaluate metform if CrCl < 40 (ok)

b.       SGLT-2 (empagiflozin, etc) inhibitor if stage 1-3 and DM (can go down to egfr of 30)

c.       GPL-1 agonist (liraglutide)  (no good evidence beyond sglt2) [contra guideline]

7.       If GFR < 60 then BP < 140/90 (I think this would be for most people)

8.       Do cystatin-C GFR one time (never unless paraplegic or loss of muscle mass – amputation) [contra guideline]

9.       If not Diabetic need at least one renal imaging study [I made this one up, but seemed to follow] (sure)

10.   Apply Kidney Failure Risk Calculator (Navdeep Tangri, MDCalc) (sure)

11.   Stage 3 and above: dietary consult

a.       Bicarbonate supplementation if metabolic acidosis (if bicarb < 18)

b.       Dietary sodium restrictions (yes – for all those with htn)

c.       Protein 0.6-0.8 g/kg/day (skip this one – good evidence – hard to do) [Curbsiders had recent podcast saying same]

12.   Stage 3 and above need a PTH measured (never measure pth in ckd unless hypercalcemia) [contra pocket card guideline so many a mistake in that]