Monday, December 12, 2011

J & B - a 2011 Review

John & Barbara
Christmas 2011

Hint - click on any picture to enlarge it 
Rather Sporadic, like our life, but here is a note of the clan happenings lately. It would be easy if we could just say we worked, hung around the home, and read a few books, but fortunately we were able to get around a bit again this year.

In January Barbara left ahead of John for Palm springs, doing a “ricochet” road trip with Joanne, one of her girl friends. We departed the desert early this year for purpose; a March wedding! Karen and Brian were wed in a beautiful ceremony (and rocking reception) in Tucson in late March. It was a formal wedding, but with a notable lack of stress and abundance of fun. After the honeymoon, Karen, now a board-certified psychiatrist, is back in her practice and Brian has taken advantage of an opportunity to expand his law practice. They have all the paperwork in place for adoption and hope to be parents very soon.
June found us on the way to England, Norway, and Denmark with Dale and Ann Roberson to see the fjords and Some of Dale's family. We started in London, where Barbara And John had lunches with English friends, both old and recent. Barbara, as usual, uncovered things off the beaten path, this time a Victorian operating theater (pre-anesthesia and pre-antisepsis) for the Guys Hospital women's wards that had been closed off for construction, forgotten about, and then discovered as a veritable time capsule more than a hundred years later. 

We then embarked for a cruise along Scotland , the Norwegian fjords, Bergen, and Oslo, winding up with a few days in Copenhagen.  Barbara again searched the side streets, leading us to a Leper Hospital in Bergen from the 1700's and an old medical school and hospital in Copenhagen that contained a remarkable collection of the very earliest X-ray equipment.

On the shore day in Flam, the Floyds and Robersons rented a car and spent the day visiting with Dale's family and touring the family farm and homes and the wonderful, old church. To add a bit of excitement, we left the family at the last minute, drove like mad ( including a ferry connection and the longest automobile tunnel in the world), and made it back to the ship just as they were raising the gangplank. Participating in Dale's family connection was the highlight of the trip.

In July, John drove our motorhome as the support vehicle for Matt (John) and two of his friends on RAGBRAI as the boys (and 10 or 20 thousand others) did the annual bike ride across Iowa from the Missouri to the Mississippi. Fun (and air conditioning) for all. While Matt was conditioning for RAGBRAI, Rachael was in Portland training for half-marathons (challenged by her mom, who travels to Portland for the races.) M & R seem to be thriving in Portland (great city!)
Anne is back in School in Phoenix and will soon join her siblings as college graduates. She is on the Dean's List! RC continues to work in what in Phoenix is a very challenging real estate business. They drove to Estes Park in August, joining Matt, Rachael, Karen, and Brian so all could celebrate with us our 40th wedding anniversary . . . the best present we could have.
We were in Estes Park for much of the Fall (with John commuting of course.) It remains a remarkable place. This year we had a mother bobcat park her 3 kittens in a tree next to our deck for the afternoon and evening; pictures ended up in the local paper. We had a visit from Barbara's cousin Steve and wife Janet and a couple of visits with John”s cousin John and wife Donnice who live in Fort Collins. It was a great opportunity to stay in touch with our many friends in Estes Park, many whom are neighbors on our street.

In early November, we combined taking the RV to California with a trip to Green Valley, AZ for
a weekend celebrating Tom and Elaine Ferguson's 50th wedding anniversary – what a party! It was also a chance to see friends from our old gourmet club.
We did a slight twist on our annual visit to Chicago for the big radiology meeting the week after Thanksgiving by not using an hotel, but staying in a condo (owned by a friend of a friend) a block from Water Tower. Chicago has long been our favorite city for downtown living/visiting, though we must say that now we are getting to know Portland, OR, it too has a great downtown.
We will be heading back to Estes Park for Christmas and New Years, and be joined there by Matt/Rachael and Karen/Brian. Ann and RC might or might not be there because of medical issues with his family in Cedar Rapids.
Barbara keeps adding to the family history, with research here and there across the country. In addition to working in the Newberry library in Chicago, she “discovered” one of the best genealogy libraries in the country in Fort Wayne, IN, and combined a visit there with a trip to attend a memorial for Bill Wilson, her aunt's husband, in Princeton, IN. Barbara also continues to hone her jewelry making skills. This year she moved from student to teacher, leading two classes in chain maille at a local shop here in Cedar Rapids.
John still enjoys his practice, and has committed to working through 2012. Next summer he will decide about 2013. He relishes those days without the alarm clock going off, and could learn to live that way all the time.
We wish all of our friends and family the best for the coming year. We cherish each and all of you and we are thankful we have you in our lives.

(Winter Holidays in Estes Park
from our bedroom window. )

John & Barbara

Saturday, December 3, 2011

Rationing Health Care: good or bad it's necessary

Book Cover 
"Pricing Life" by Peter Ubel

The USA is going to have to decide what to do about the rampant acceleration in the cost of health care on a national basis, and I am fearful that, lacking the knowledge and courage to do it correctly, the government will simply continue cutting payments across the board to doctors and hospitals, encourage the use of cheaper but less effective care, and continue to ignore the growing tens of millions of citizens without health care insurance.  
PRICING LIFE is one of the few books to use the "R" word (rationing) even though we are already  rationing care in this country; just doing it irrationally.  My daughter, K put me onto this book almost a decade ago, and it is every bit as valid today as when it was published in 2001.

Ubel reviews the many ways rationing has been attempted (with noteworthy experiments in Oregon that were well conceived but still unsuccessful), including prioritizing with cost-effectiveness analysis (CEA) and cost-benefit analysis (CBA) as means to determine the utility of different medical treatments in adding a quality year of life (QALY.)  He comes to the conclusion that these efforts have failed because they don't reflect all community values and only address the average patient.  He contends that only by primary physicians limiting use of and access to marginally beneficial care can substantial reductions in medical utilization and cost be achieved.  He discusses the way physicians are already rationing care by the use of situational examples.

Ubel also talks about the "Moral Hazard" of insurance, even when individually purchased.  This is a phenomena well known by waiters in high priced restaurants.  When there is no splitting of the check, the overall bill will invariably be higher than if individual checks are given.  When Bill is dining with 5 other friends at an expensive restaurant, he is more likely to order his third expensive scotch after dinner since he will be responsible only for $10 (1/6) of the actual $60 cost of his three drinks, while Mary may have the fancy desert she thinks is overpriced and would not otherwise order, but because she sees Bill having all that expensive Scotch she also wants to get her own "fair share."  

This same process acts with insurance, especially when employer or government provided.  If your doctor says there is a test that cost $500 to detect a rare disease that you have only a 1 in 10,000 chance of having, you will probably decline to have the test if you have to pay the $500 out of your own pocket.  However, if covered by insurance and you only have to pay $10 to have the test, you are far more likely to ask you doctor to go ahead with the test.  Thus the "moral hazard" of medical insurance works just like the expensive dinner with a single check.

I do think there is an important component missing in Ubel's book, and it is perhaps because his experience is as a government-employed VA doctor, and because the "business" of medicine has increased in dominance since the '90s when he wrote the book.  I know of no hospital that does not operate on a profit basis; especially a "non-profit" hospital that is in competition with another non-profit in the same community.  

As I have commented earlier, medical groups are also operating on the profit model.  Urologists buy a complete radiation therapy installation, since there is much more to be made from the technical fee for a course of radiation therapy for prostate cancer than from a surgical fee for a prostatectomy.  Orthopedic surgeons install MR scanners in their office and make more money from sending patients to the MR than they would ever make from consultations and examinations in their clinic.  Ditto for Cardiologist, oncologists, etc. etc.  The financial incentives for over-utilization are tremendous.

I see nothing in the behavior of our government members to suggest that they possess the moral fiber to tackle and solve the health care cost and availability problem anytime in the near future.  Only when a crisis brings a consensus in the citizenry that we must accept some degree of rational rationing, and we make it clear to congress and the President that we are willing to accept a fair and rational national health care policy for all our citizens will there be any chance at all to alter the path we are currently on to a complete implosion of  health care in the USA.

Saturday, November 19, 2011


Epicurism: The pursuit of sensory pleasure.

Epicureanism:  The natural and moral philosophy of Epicurus.

The Nature of Things:  The magnificent poem by Lucretius presenting the philosophy of Epicurus

It has been my intention over the past 10-15 years to become better informed in the Greek Philosophers.  Naively, I started with the names with which I was most familiar; Socrates, Plato, Aristotle.  It was difficult reading, and I tended to lay the books aside, because I just wasn't getting much satisfaction.

I had another chance to try some heavy, but in this case wonderfully rewarding, reading over the past two months after listening to an NPR talk show discussing a poem by Lucretius, The Nature of Things.  It seemed this poem described things made of atoms flying around largely empty space and a world in which the pursuit of happiness occurred within a moral philosophy of humanistic concern.

 -  De Rerum Natura (The Nature of Things) by Titus Lucretius Carus - Translated by A. E. Stallings
 -  Epicureanism at the Origins of Modernity by Catherine Wilson

 -  The Swerve: How the World became Modern by Stephen Greenblatt

There are no primary documents left to us by Epicurus (Greek, 341-270 B.C.E).  Most of the contemporary writing from his time is that of other philosophers,and most were critical of Epicureanism.  Diogenes did summarize Epicureanism in his review of Greek philosophers.  Epicureanism was incompatible with any of the cults of the Greek or Roman gods, and was later considered by the Christians to be heretical.
There is a singular record of his teaching written around 60-50 B.C.E. by an Epicurean student and Roman Citizen, Lucretius,  in the form of a poem.  Oh, but what a poem.  More than 7,000 lines, no characters and no story, but perhaps the most beautiful presentation of thought ever recorded. (Try the poem's 4th book  for maybe the most intense description of human physical love you will ever read.)  Lucretius said by placing a rim of honey (his poetry) around the rim of the glass, one would be more likely to drink the contents which otherwise seemed strange or even unpalatable.

However, it is not the shear beauty of the poetry that overwhelms me, but the incredible insight into nature provided by the Epicurean philosophy.  His prescient concept of a world made of atoms and empty space preceded "modern" science by almost two thousand years, and was the basis for the science of Newton, Galileo, and others.  He suggested the basis for evolution long before Darwin and even discussed a "probability" of particle movement and location, hinting at the "new" science of quantum physics.  There is an excellent summary (and drawing of Lucretius) in this New Yorker article.

In Epicurean morals, pain is an unqualified evil.  Because death is the end for each sentient being, we should enjoy ourselves to the extent that our enjoyment of present pleasures does not diminish the quantity of pleasure we can enjoy in the future, to the extent that our present enjoyments do not destroy health, bring down the wrath or contempt of others upon us, or subject us to the torments of guilt and regret.  Moral wisdom consists not in ascetic practice, but in prudence and foresight, for experience of mankind assures us that moderation and avoidance of dissipation tend to make for a less painful life.

Thomas Jefferson had 5 Latin editions of The Nature of Things, and one each in French, Italian, and English.  He wrote to a friend "I too am an Epicurean."  It is no surprise that the Declaration of Independence speaks of the right to "the pursuit of happiness."  In a letter to William Short Jefferson writes: 

"I take the liberty of observing that you are not a true disciple of our master Epicurus, in indulging the indolence to which you say you are yielding. One of his canons, you know, was that "that indulgence which prevents a greater pleasure, or produces a greater pain, is to be avoided." Your love of repose will lead, in its progress, to a suspension of healthy exercise, a relaxation of mind, an indifference to everything around you, and finally to a debility of body, and hebetude of mind, the farthest of all things from the happiness which the well-regulated indulgences of Epicurus ensure; fortitude, you know is one of his four cardinal virtues. That teaches us to meet and surmount difficulties; not to fly from them, like cowards; and to fly, too, in vain, for they will meet and arrest us at every turn of our road."

Some proposals within The Nature of Things:

* Invisible particles constitute everything in the world, and all things are made of indivisable "atomes" or "Seeds" and empty space.
* These atoms are limited in shape and size, but each shape and size is infinite in number.
* These particles are always in motion within an infinite void.
* The particles do not travel straight, but "swerve," collide, hook together, come apart.
* Aggregation of atoms produces visible objects, plants or animals.
* When these things die or undergo dissolution, these atoms are dispersed back into the world, available for construction of new things.
* Nature continuously experiments.  Things better adapted increase in number while things less well adapted disappear.
* The universe has no creator or designer.
* The universe was not about nor created for humans.
* Humans are not unique nor fundamentally different from other animals.
* The soul is inherent to the physical body and dies with the body.
* There is no afterlife
* Death is nothing to us, neither pleasure nor pain nor longing nor fear.
* Organized religions are superstitious delusions.
* Religions are always cruel.
* There are no angles, demons, or ghosts.
* The highest goal of human life is to maximize pleasure and minimize pain.
* The greatest obstacle to pleasure is not pain, but delusion and anxiety.
* Awe and wonder come from understanding nature.

 "The Swerve" is a shorter, more readable text, most concerned with how the poem survived the sac of Rome and and the Catholic inquisition, to be discovered just in time for the evolutionary ideas of the Renaissance and the Enlightenment. Wilson's lengthier text is more comprehensive, academic, and therefore a bit more of a challenge as a weekend read.  A.E. Stallings' translation of "The Nature of Things" is touted as excellent and  probably the best available english edition.
"Unlike social and financial status, which are unlimited,
Peace of mind can be wholly secured"


Friday, October 7, 2011

The Word "Lucrative" Should Have no Place in Healthcare

First, you should precede this discussion by reading OVERDIAGNOSED  by Welch, et al in which he discusses in depth the various test, diagnoses, and treatments which they feel do significantly more overall harm than good.  As one of many, many examples, he discusses at length the use of the PSA test for prostate cancer, which is currently under intense public debate.

I have recently received an unsolicited email invitation to enlist a company which will allow me to directly refer patients for sleep apnea testing, and with no further effort on my part they will send the patient a home test kit and, if they test positive, suggest I then arrange for the company to send the patient a CPAP machine from Philips.  This was sent specifically to me as a radiologists!  They will bill Medicare of the insurers on my behalf and send the the checks.  One of their user endorsements suggest “It’s elegant and lucrative.”  They suggest that tens of millions have asymptomatic sleep apnea, so everyone is a candidate for testing. They are not targeting specialists who deal with sleep disturbances, but anyone and everyone who has contacts with patients - "The MD Home Sleep Program is ideal for physicians and dentists regardless of specialty. Primary care physicians, nurse practitioners, physician assistants, anesthesiologists, psychiatrists, and others have joined the program."

I have no doubt that many health care providers will take them up on this as a means to "enhance" their practice revenue.  No question, sleep apnea is a real disease, with real consequences, and patients needing appropriate diagnosis and management is important.  However, this proposal seems geared primarily for profit.

I have seen similar offers for simple audiometry machines (for which insurance can be billed for the same amount as if the test were done in a full audiology suite with a sound-insulated room and sophisticated electronics)  with the pitch that "everyone" could have some hearing loss, and therefore you can justify testing every single patient that walks through your door.

And you wonder why healthcare cost are out of control?

The email I found in my inbox this morning:

Dear Doctor,
Radiologists are becoming an integral part of identifying patients with obstructive sleep apnea. (a physician recruiting company) is pleased to offer doctors of ANY specialty a new and innovative way to provide convenient care to patients who may have sleep apnea while capturing additional revenue. Doctors are provided with everything they need--including education--to diagnose and treat sleep apnea. Here is a recent press release about the program.
Please take a few moments to review this website. You can directly sign up for the program by clicking here. There is no fee to join or participate and doctors are not required to buy equipment or invest money at any time. 
What are physicians saying about the program? “The administrators are courteous and helpful and the program is easy to use. I'm not a sleep doctor, but I feel equipped to treat sleep apnea now. I was initially worried about billing and reimbursement, but that worked out wonderfully too and I received my checks on time, as promised.” -MAM, Internal Medicine from New York

If you have questions or would like to discuss this opportunity further, please contact me.

Thank you,
(a physician recruiting company)

The Pitch:

Aviisha’s MD Home Sleep Program continues its rapid growth as physicians and dentists join to diagnose and treat obstructive sleep apnea.

Los Angeles, California (PRWEB) July 19, 2011
Sleep physicians and non-sleep physicians are gathering to diagnose and treat obstructive sleep apnea (OSA) via the MD Home Sleep Program (MDHSP). Spearheaded by its Medical Director, Dr. Abraham (Avi) Ishaaya, the program was designed for the convenience of both patient and physician.
MDHSP is the creation of the Aviisha Medical Institute, LLC. Started in 2009, the program is part of a full-scale effort to fight the national sleep apnea epidemic. MDHSP simplifies the diagnosis and treatment of sleep apnea while helping patients avoid expensive lab testing.
Physicians who join the program are given a variety of screening tools to identify patients at high risk for obstructive sleep apnea. “It’s estimated that one out of every five Americans has sleep apnea,” explained Dr. Avi. The disease leads to countless serious complications including stroke, hypertension, heart disease, diabetes, weight-gain, depression, anxiety, and even death. Dr. Avi continued, “The consensus in the medical community is that patients who snore, have daytime sleepiness, or suffer from diabetes, hypertension or heart failure should be screened for OSA immediately.”
Cutting-Edge Home Sleep Testing and APAP
Using Aviisha’s revolutionary technology (patent pending) physicians can prescribe home sleep tests with the click of a button. Aviisha takes over by verifying insurance and shipping the patient a home sleep test. All patients are tested using the Philips Alice PDx portable diagnostic device, an unsurpassed, state-of-the-art device that meets the standards of Type II, III and IV diagnostic tests with up to 21 channels. The test is simple to administer and produces highly accurate results.
Aviisha scores the test and sends the physician a straightforward report with diagnostic and treatment recommendations. Physicians can prescribe Auto-CPAP therapy (APAP) just as easily as they prescribe the home sleep test. The device, a Philips System One REMstar Auto-CPAP machine with A-Flex ships directly to the patient. The device automatically adjusts its air pressure according to the patient’s individual needs, reducing unnecessary air pressure by up to 40%.
Aviisha also manages treatment compliance and generates periodic reports for physicians. “We’ve designed the program in such a way that the physician’s main responsibility is identifying patients at risk for sleep apnea,” said Alazar Yinbal, Aviisha’s Chief Executive Officer. “We do the rest.”
New Website Empowering Physicians
Physician need not be sleep specialists to participate in MDHSP. A battery of newly published webinars, articles, tools, and resources empower physicians to evaluate patients and prescribe diagnostic tests and treatment. “The program does a wonderful job of giving me the information and tools I need to feel informed and prepared to treat sleep disorders,” said Dr. A.M. Mirza, a physician specializing in Internal Medicine from New York. “It’s elegant and lucrative.”
The website features a brand new Sleep Apnea Education section containing free articles, videos, slideshows, diagnostic tools, and resources about sleep apnea. Monthly webinars hosted by Dr. Avi highlight different aspects of sleep apnea and are open to all medical professionals. Dr. Avi explains, “We wanted to educate doctors about sleep apnea and ensure that they felt not only comfortable but confident in their medical decisions.”
The hard work seems to be paying off. MDHSP physicians have reached an impressive 85% conversion ratio from home sleep test to positive diagnosis. Not only that, its current treatment compliance rate is over 74%, almost twice the industry’s average.
The MD Home Sleep Program is ideal for physicians and dentists regardless of specialty. Primary care physicians, nurse practitioners, physician assistants, anesthesiologists, psychiatrists, and others have joined the program. There is no fee to join or participate and physicians are not required to buy equipment or invest money at any time. The program serves in-network, out-of-network, and Medicare patients.

Sunday, October 2, 2011

The "Other" Color Tour

When one thinks of the fall display of color that brings on the tour buses, photographers, and Sunday afternoon drivers, most people, as did I, immediately call up images of the New England hills in late September and October. That has changed for me.

This change happened yesterday, Oct 1, 2011.  I have occasionally seen some great color in the Colorado Rockies, including here in RMNP, over in the ski areas along 70, and up in Steamboat, but have not spent enough time here in the early fall to experience the peak color very frequently.  However this year, the colors are this weekend spectacular, and we are here!

Estes Park has been busy, as usual, with all the visitors for the elk rut and the various fall festivals here and in nearby foothill communities. Add all the TV newscast telling people to head to the mountains for the color, and our town has been PACKED this weekend.  Making a run to the Safeway or to Kind Coffee for a cup is a challenge, taking 15-20 minutes each way (rather than the usual 5 min.)  I am happy for the merchants (who generally feel it has been a good season already), but look forward to getting a little sanity back.
Yesterday, another couple on our street and Barbara and I drove down Hwy 7 where there was vista after vista - literally around every turn in this mountain road - of beautiful stands of aspen, mixed among the pines, with yellow, gold, and orange leaves quaking in the gentle wind.  It was late in the day and depending on the direction of the road and where the vista was directed, the leaves would either be shining in the late day sun or glowing with the light shining through the leaves.  It was partially cloudy, so the mixture of sun and shadow, the low angle of the sun, and the continually changing views of this brief, but perfect display will probably stay with me until most everything else has faded.  We wound up the afternoon drive with a superb dinner in the restaurant a the Isle in Blackhawk.

I would still like to tour New England in a good year for color, but I don't feel too deprived anymore.

Sunday, September 11, 2011

A Book about Words (THE BOOK THIEF - Markus Zusak (Australian) 2007))


"The force which has ever and always set in motion great historical avalanches of religious and political movements is the magic power of the spoken word ." "It is only through the capacity for passionate  feeling that chosen leaders can wield the power of the word which, like hammer blows, will open the door to the hearts of the people."

Mein Kampf 
Adolf Hitler

I read the introductory portions of Mein Kampf several years ago mainly out of curiosity, but also in an effort to understand Hitler and his role in history. He was no dummy, and his climb to leadership involved no luck or happenstance.   Hitler understood, long before his rise to leader of the Third Reich, that words, in conjunction with passion, can change the course of history.  Certainly no one can deny the power of his spoken words in affecting 20th century events.
Friends have asked me what the book is about.  I suggest it's The diary of Ann Frank as narrated by Kurt Vonnegut.  (OK, so I've already linked Kurt Vonnegut to Stephens Hawkins, but I seem to have Kurt on the brain lately.)  The Book Thief  by Markus Zusak , like Slaughterhouse 5, is an antiwar novel in that it strips all nationalistic glory and higher purpose from the battlefield; though that is not why I throw in the Vonnegut comparison.  The similarity is in the use of an abstract narrator to tell the story of the protagonist and supporting characters, and to address the horrors of Nazi Germany through these characters (military characters in Vonnegut's case and civilian characters in Zusak's novel.)  I will say that Zusak's novel is not nearly so off the wall as Vonnegut's writings, and and focuses on Nazi Germany rather than nationalistic wars in general.  In the end, however, it was a pure pleasure to read.
Woven within this wonderfully written story of a young girl in WWII Germany is an exploration of the ability of words to cause great destruction in the world, as well as imbue peace and hope in individuals.  The narrator of the entire book, Death, is at different points sanguine, sarcastic, sad, and funny.  He takes "souls" and speaks of "God" but from a more or less agnostic position.  He complains of how much work there is to be done during the war, and wishes he had a vacation, but alas, there is no one to replace him.  His concluding words end the book:  "I am haunted by humans."
A "discussion points" appendix was present in my book, but I was not impressed by the questions it suggested for discussion.  From a book club position, I think an analysis of the literary style would be as germane as a discussion of the plot and narrative details.  Zusak is a real wordsmith.

Is it a sad book?  Clearly.  Is it a happy book?  Most certainly.  Should you read it . . . definitely!


Tuesday, August 30, 2011

Should "religious" equal "tax-exempt"

Average community church
The foundation of Scientology

L Ron Hubbard was quoted many times in newspapers, and through other reports to have said numerous times something to the effect "You don't get rich writing science fiction. If you want to get rich, you start a religion," and from this marginal science fiction writer sprung the "Church" of Scientology.  Now I don't have a lot say about what other people believe and to whom they give their money, but it really tics me off that Scientology (including their celebrity members) uses our tax code for patently non-religious (and a lot of rather occult) purposes, and they are not the only one.

My father (a minister himself) was strongly against the unlimited tax breaks for religious organizations, and talked with me about it several times.  He expressed his opinion that there should be a modest ceiling tax exemption based on daily attendance or some similar verifiable accounting of active members.    He thought, beyond that limited ceiling, churches should pay taxes on assets and on income that exceeds certain operating expenses. Book stores, media production companies, parking lots, gymnasiums, skate board parks, high-rise office buildings,  and sea side villas and pent house apartments.....he could see no justification for the general population of taxpayers to be taxed more heavily to offset the funding (through tax relief) of any and every thing under the umbrella of "Religious" activity.  

Clearly churches do many good works through assistance to the needy of the world.  On the other hand, some churches spend virtually all their income to build lavish buildings, buy real more estate, purchase radio and TV time, lobby government, and provide a very nice income/benefits package to people who supposedly have renounced earthly rewards.
I like my father's idea to limit the tax-free income to a religious organization, perhaps based on membership (e.g. a few thousand dollars/member), or perhaps by meeting a threshold percent of income that is actually spent directly on aid to the poor or sick.   I personally do not donate to a charity or non-profit that spends more than 10% of its budget on salaries, fund-raising, etc.  I also give a fair amount for purposes I think are worthwhile and of benefit to needy people, but for which there is not a tax-exempt vehicle.  As it is however, my own taxes are diverted to support some things that I independently would choose not to support, or would only support via a different vehicle.

You should tax the things you want less of, and not tax the things you want more of.  However a blanket pass for anything managing to get called a "church" has led to abuse, and it is time to apply some rational limits.  After all, charity is charity, and should come from one's own heart, not from an accountant's advice.

Tuesday, August 23, 2011

Was Kurt Vonnegut a Literary Stephen Hawkins?

The "banning" by Republic High School in Missouri of Vonnegut's classic anti-war novel, Slaughterhouse-Five, or The Children's Crusade: A Duty-Dance with Death (1969), prompted me to pull out my old, yellowed copy, saved since my original reading as an escape from the pressure of my final year in medical school, to see exactly what had prompted the action (After re-reading the book, it seems the removal from the school library was because some of the characters thoughts or actions could be considered "non-biblical" - in which case any novel about Hitler, etc could be considered non-biblical.) I am, however, confident that the banning, rather than saving the students from exposure to Vonnegut's book, assured most of the students at the school will now read the book over the ensuing weeks.

Forty years older now, my reaction is still mixed, though I see the anti-war sentiment more clearly, having by this time considerably lowered my expectations from our political "leaders."

What did strike me on my current reading were certain parts of the story of Billy Pilgram. "Billy Pilgram has come unstuck in time . . .is spastic in time." He tells the story of being captured by the alien Tralfamadorians (who see in four dimensions  - adding time as a visual dimension) and learning that "when a person dies, he only appears to die. He is still very much alive in the past, so it is silly for people to cry at his funeral. All moments, past, present, and future have always existed, always will exist."

If you have read Hawkins' book The Grand Design and one of his Brief History of Time books, it is apparent that current quantum physics and relativity more or less supports this claim by Vonnegut's character of the past, present, and future concurrently existing.(In fact I find these discussions of  time to be very, very strange, and it is suggested that before the big bang, time may not have existed.)   Kurt was not a physicist and never claimed any knowledge of quantum physics, but intuition can sometimes get you a long way.


The Ghost in the Wires - The biography of the "most wanted hacker in America."  Kevin Mitnick now owns his own security consulting firm.  This Link to his website currently has a video of his interview on the Colbert Report - very entertaining!

Matterhorn - a most disturbing novel of the Vietnam conflict. Having no firsthand experience, I will need to consult with my cousin John C as to the accuracy of this book

Monday, August 8, 2011

A Perfect Pair

(I have been traveling a lot this summer, and the between travel time has been very busy.  Hopefully I can spend a little more time uptading this blog going forward.)
     Sometimes I read for information; sometimes I read for pleasure; and sometimes I am lucky to find a bit of each in the same book.  Once in a very, very great while I find two such books that are informative, most pleasurable to read, and compliment each other.  This year I found (by watching BookTV one Sunday morning and catching an article in the NYTimes another day) two books providing to me this unusual pleasure: "Doc" and "The Last Gunfight."

You can read a full summary of each book at Amazon or elsewhere on the internet, but here is my perspective on these two coincidentally related books.
What you know, or think you know, about John Henry Holliday, about Virgel, Warren, Morgan, James and Wyatt Earp, and about Bat, James, and Ed Masterson is likely misinformation.  After the violent events in Tombstone, there were many sensationalized accounts of the various involved characters, often embellished by the principles themselves, and the myths have been perpetuated by Hollywood over the years.  These books use original research from the surprisingly large volume of notes, newspaper articles, and official records scattered in various libraries and historical institutions across the country to reconstruct the personality, character, and actions of these players.
Although these books were written by very different authors over the same period of time, they chronologically dovetailed perfectly.  Russell has a PhD in biological anthropology from the University of Michigan and has taught anatomy to dental students. Her book is a biography of the most interesting character of John Henry "Doc" Holliday, beginning with his birth, but ending with his time in Dodge City, Kansas.  It notes his departure for Arizona, but goes no further.  We know at this point (even if we have not read Guinn's book) that he will achieve fame in Tombstone (on a street, at the edge of a vacant lot, sort of close to the OK Corral.)  It is inclusive of the Earp and Masterson brothers, as they are an integral part of his life in Dodge City, and also is quite inclusive of the women who for the most part were informal partners or common law wives of these men.
Guinn was a school teacher, then newspaper journalist, and finally published author (I believe his first major book concerned the outlaw couple Bonnie and Clyde.)  Rather than a biography, "Gunfight" is a story of Tombstone, Arizona; its origin, rise, and fall (and then re-emergence as a tourist trap.)  As it happens, these same characters (Holliday, the Earp brothers, and the Masterson brothers) also populate the history and legend of Tombstone, and it brings to a conclusion Doc's biography..  (Unlike Russell, Guinn doesn't have as much to say about the women.)  His followup extends to the final days of Wyatt in Los Angeles, and Doc and Bat in Colorado, as well as the literary and film spinoffs that followed for the next century.

As far as I can discern, these writers worked completely independently, were coincidentally both published (by different houses) in May 2011, and by apparently blind happenstance one concluded almost exactly where the other began.  They agree for the most part on the personality and character traits of Doc and the Earp brothers.
The books are written in different style.  "Doc" captured my attention from the first page.  "Gunfight" started slow (and dry), but quickly evolved into a "good read" of its own.  I stayed up way too late several nights with these books.  I cannot think of any of my friends who will not find these historical accounts of America's "last frontier" most enjoyable - and informative to boot.

Doc is buried in an historical cemetery on a hill above Glenwood Springs, Colorado, where I took this picture a couple of years ago.  The cemetery is only accessible via a switchback trail from a small park on a street below the hill.

Wednesday, May 25, 2011

Books of Influence

     My daughter Karen recently asked me to list my 5 "favorite" books.  She explained further "I don't mean just the books you enjoyed reading the most, but those that had the most influence on your life.  I think it may tell me something about who you are."
     I thought this would be a quick, easy task, but that was a serious underestimation; I have read many, many books, and as a person I am clearly still a "work in progress,"  so picking out the most personally influential books took a lot of thought. 
     Here is the result of my considerations with commentary and with links (in blue) to the Amazon description should you want that information.  It's actually 5 books plus 6 more . . . sorry about that Karen.
     There is little fiction here, but my view of the world has undoubtedly been influenced by novels such as  Moby Dick, For Whom the Bell Tolls, Grapes of Wrath and Doctor Zhivago, all which I read in Junior High School.  Also, I should note that this is a snapshot in time.  If I had done this list a year ago or if I should do it again in a year, it would likely be somewhat different.  JLF

The Prophet - Kahlil Gibran
Among the first philosophical writings I experienced, I was introduced to Gibran by Barbara when she suggested some of his writing be integrated into our wedding ceremony.  The Prophet is Gibran's poetic distillation of his philosophy, economically worded and grouped as commentary on love, friendship, marriage, giving, etc.  I still quote him:.  For example, "Grieve not when you part from your friend, for that which you love in him most may be clearer in his absence, as the mountain to the climber is clearer from the plain." The Tao Te Ching  by Lao-Tzu, which I read at about the same time, I found a little more distant for me, personally.

Humanist Anthology: From Confucius to Attenborough - Margaret Knight (Editor)
The Anthology has been around for years, first published in 1961, but unfortunately not discovered by myself until years later.  Had I stumbled across it as a high school student in '61, my younger days would likely have been substantially changed.  In essence, it is a series of ancient, recent and contemporary essays that as a collection illustrate the constancy of humanism over many centuries and document it as a well developed philosophy rather than a recent reaction to organized religion.  Albert Einstein, Robert G. Ingersoll, Umberto Eco, Carl Sagan and Christopher Hitchens are simply the most recent in a very, very long line of humanist following in the footsteps of Confucius, Thucydides, Epictetus, Epicurus and Spinoza.

Practical Ethics - Peter Singer -
I always assumed that I was raised with "ethics," but this was my first organized review of "ethics" as a philosophy. Practical Ethics was, and still is, a compact introduction to the thinking by which one begins to understand the processes we might apply in making the decisions we face moment to moment through our lives.  I read this 20+ years ago, but in the latest revision Singer has apparently updated and expanded his original treatise.

Why I am Not a Christian - Bertrand Russell - 
As a philosopher, mathematician, educator, social critic and political activist, Russell authored over 70 books and thousands of essays and letters addressing a myriad of topics, but this very short essay is likely his most widely read work.  I suspect that is because it speaks so effectively to those reared as Christians but questioning personally this faith.   Why I am not a Christian is a brief essay initially published in self-defense as a response to wide, public criticism by churches, politicians, and media (mostly in the U.S.) of Russell's lack of professed Christian belief.  (The link here is to the essay itself, not

The Denial of Death - Ernest Becker -
"The essence of normalcy is the refusal of reality." I read this  psychology text about 7 or 8 years ago with a specific purpose to contemplate and consider my mortality, but I am sure I did not understand in depth the underlying psychological foundations for his work.  Becker, an American Cultural Anthropologist, published Denial, won the Pulitzer prize for the book, and died of cancer all in the year 1974 at the age of 50. The thesis of his work was that individuals live in terror of their own mortality and thus seek to find ways to deny it.  He ask how can we, as human animals, relish day to day life, explore the cosmos in theory and reality, plum the depths of human psychology, and yet at the same time live with our impending death?  He then suggest that the most common reaction is the denial of this reality and argues that as this fear of death is denied and repressed, it then comes out in predictable patterns, particularly in the development of culture and the monuments we build--financial, literary, intellectual--to reassure ourselves of our immortality, or to gain, in Becker's words, "symbolic immortality."   He is fairly kind to religion, seeming to me to suggest its prevalence is perhaps because of its success as a means of dealing with the conundrum. For those who have made the decision to tackle this "urgent" issue, Becker's book is an important read, and will likely become a "re-read" for many of us. An award-winning film that is an extension of this book has been produced: Flight from Death is available via netflix and iTunes.

- Additional books of significance -

Man's Search for Meaning - Viktor E. Frankl 
Search was composed in Frankl's mind (no access to writing materials) while a prisoner in the Nazi death camps, principally Auschwitz, and placed in print shortly after the war.  The first half is his personal narrative of the camps, uniquely told from the perspective of the psychiatrist he had been, and the second half is his reflection on how one must find "meaning" in life, even in the face of incredible suffering, and how he uses meaning in his field of "Logotherapy."

The Grand Design and also A Brief history of Time -  both by Stephen Hawking -
One should be able to appreciate the wonders of the cosmos, whether you believe it is the creation of God or actually did arise from nothing (by dividing into (simplistically) "matter" and "antimatter" which together have a sum mass/energy of nothing.)  Hawkins atheism should not prevent anyone from enjoying this discussion of our fascinating universe in physics terms that most of us can grasp with a little effort.  Design is a followup to Time  should you want to read them consecutively, though Design stands perfectly well on its own.  Along that same line  Cosmos was the stunning 1980 TV series by Carl Sagan that introduced millions of people, including me, to the scientific cosmology of our universe.  (His fiction book "Contact" reveals much of his thought on religion and philosophy.)  Neil deGrasse Tyson has picked up the standard as the premier scientist-educator of our time, but it was Sagan who first made it respectable for a scientist to talk science to the common folk.

The Battle for God (Originally subtitled "The Role of Fundamentalism in Islam, Judaism, and Christianity?) - Karen Armstrong -
I have read many of her books, including her biographical The Spiral Staircase and Through the Narrow Gate. Perhaps more than any other book, Battle gave me an insight into religious fundamentalist, among which are some personal friends. Be it Islam, Judaism, or Christianity, there is a dangerous tendency to lose the compassion that is at the core of any authentic religion, and to degenerate into "a theology of rage and hatred."  But at the same time, secularists and people with more liberal notions of faith need to recognize the real fears that fundamentalists face, and deal with the problems that spawn those fears. "Fundamentalists are not going away. We need to understand them."

Zen and the Art of Motorcycle Maintenance - Robert Prisig -
 Zen  has to be on the list as having influenced me early on; I read it for the story, but the philosophy lingered on.  I was living in England and spending most of my time working, traveling, and marveling over our second child (Karen herself) when I first read this book, which contains little about motorcycle repair and even less about Zen Buddhism, at the age of 30 in 1975.  It is a road trip story used as the framework for philosophical musings.  Some of my favorite quotes from this remarkable book:

"The place to improve the world is first in one's own heart and head and hands, and then work outward from there."  

"We’re in such a hurry most of the time we never get much chance to talk. The result is a kind of endless day-to-day shallowness, a monotony that leaves a person wondering years later where all the time went and sorry that it’s all gone. " 

"The pencil is mightier than the pen."  

"When one person suffers from a delusion, it is called insanity. When many people suffer from a delusion it is called a Religion." 

"We have artists with no scientific knowledge and scientists with no
artistic knowledge and both with no spiritual sense of gravity at all,
and the result is not just bad, it is ghastly." 


Friday, April 29, 2011

Shifting cost is NOT healthcare reform!

I am getting tired of the shell game some prominent people are playing with their proposals for health care "reform" in this country.  Almost every proposal is essentially an effort to shift the cost this way or that rather than actually reform health care in the U.S.

Take an analysis of the proposal by Rep. Ryan (  If you look at the graphs, he "saves" the government Billions of dollars only by shifting Trillions of dollars of unfunded future health care cost to future medicare beneficiaries.

You can argue the exact amounts, but in fact the plan bails out the US Government only by shifting the future increases in health care cost to the individual senior rather than doing anything to limit the growth in that cost.   He assumes that somehow (supernaturally it seems) that giving people a voucher will allow them to purchase benefits similar to what they now enjoy in a competitive market, and that the cost of such a plan will not outpace inflation in future years.  Of course, all you have to do is look at the history of health care cost to see that this is not going to happen without a fundamental change in how we buy and deliver health care in this country.

Seen from the inside, the third party payers, including CMS (Medicare,) have used several tricks to cut the cost of care.  First, they simply pay less and less for a service, with little actual investigation of which services are relatively "overpriced" compared to others.  Second, they limit services through vetting - often rationing through inconvenience.  This has primarily occurred in high-end imaging where requiring pre-approval for an MRI for example can be such a demanding and time-consuming process that the physicians office simply gives up on appealing a denial of coverage after spending way too much time trying to get through the company that has been hired by the insurance company to vet the request (and of course the more request they decline, the more income they ultimately make either through incentive rewards or future contracts.)  This was recently challenged in the courts where a company with an incentive contract was found to have denied an excessive number of cardiac imaging exams with no medical justification for the denials.  Third, payers are beginning to limit services to the cheapest provider or to the least expensive product. 

To respond to this hospitals and providers are doing several things. Increasing productivity, limiting overhead, and more creative ways are being used to maintain income levels (and this includes so-called "non-profit" hospitals.) We are reaching the point where only someone using a cheap, used or reconditioned low-end CT or MRI device can profit at medicare fee schedules, and there are many of these in the hands of private entrepreneurs who are more concerned with the bottom line than with producing the most informative exam.  There are now hospitals that will only give the option of using prosthetic joints, etc that have been purchased from the lowest bidder.  

 Much of what can be done has, by this time already been done, and providers are now beginning to restrict, or completely opt out of government care.  This is most critical in the Medicaid (as opposed to Medicare) programs run by the states.  Even the University of Colorado last year began limiting the number of medicaid patients they would take because medicaid patients were filling all the available appointment slots.  There was at that time reported to be no Urologist in the state  that would take a Medicaid referral.  

Medicaid problems are now beginning to get headlines as the benefits have to be cut even further still because of state budgets falling apart just as the number of patients needing Medicaid coverage increase.  Poor, unemployed people are pretty much running out of options, and even working people are finding insurance coverage impossible to obtain at anything approaching affordable rates.  The only "affordable" policies available to an individual are those with very large deductibles and high co-pays, and it is nearly impossible to buy an individual policy with maternity coverage at any price.  To compound the problem, companies are finding it difficult if not impossible to offer medical insurance as a benefit because of increasing cost.  As an employer I can tell you it takes commitment to continue to offer company insurance with consecutive yearly policy cost increases of 14-31%, even with greater deductible and co-pay requirements.

My final beef is with those who are of the opinion that "no one goes without health care in the country," suggesting that they can go to the emergency room anytime they want, and if they need hospitalization they get the best care available.  All I can say is that they have blinders on or just don't have the opportunity to see the real (lack of) care such people receive, be they in a rural county or a large city.

OK, what would I do?  I would define the goal, and that goes far beyond balancing the federal budget.  The problem funding Medicare and Medicaid is really a universal problem for all our citizens.  We should be hunting for a way to provide basic health care needs to every citizen, regardless of their economic status.  This sounds a little socialistic, but we have agreed that everyone deserves police protection, fire protection, etc, and I would at this point in our country's development add basic health care.  This doesn't necessarily mean a giant VA -type care system for the population.  The problem with Ryan's plan is that he thinks individual families can in some way negotiate with the health insurance monoliths, and that's pure fantasy.  This was tried with the Medicare Part D (drug plans) without doing anything to control drug cost.  If Ryan really wanted to do something immediately that would decrease Medicare cost he would support legislation that would allow Medicare to directly negotiate for drug purchases(Medicare is not allowed by current law to do this, I assume due to drug company influences), and thus be able to bring government drug cost more in line with those of Canada, England, France, Germany, etc. where drug cost are 30-50% less.

Unfortunately, we have been trying to make the fee for service model work, and it has failed.  We (the providers) are highly paid piece workers, and the more we "do" the more we earn.  Every hospital CEO, every group practice manager, every manager of any patient care provider is tasked with maximizing the bottom line, and to do this you have to increase volume/procedures delivered.  

In the absence of a single-payer model, there will have to be some form of capitation, where the amount you are paid is not rigidly linked to the number of procedures you do, thus eliminating the incentive to do more than is really needed, and making it important to keep people healthy to avoid future expensive illnesses.  This would include of course dental care, which is needed for maintenance of health, but never accounted for in "comprehensive" care plans.  Of course, the danger to we patients is that the company providing care over-restricts care in order to maximize short-term profits.  The Kaiser system, and I will admit that it is a far from perfect system, has a large network of salaried physicians, and must be recognized as a workable model, attempting to balance too much care versus too little care while maximizing health, rather than procedures..  This is a threat to many physicians, as in Kaiser the physicians are employees, and the higher paid specialist earn ~3 times that of a Family Practitioner (as opposed to a 20-30 fold difference in many communities.)

The government may have to define what constitutes basic benefits, and assure that the current common practice of denying major medical coverage to anyone who is likely to need it will be no longer allowed.

I may not have all of the details, but I have not read anything that indicates that these issues have been addressed by Congressman Ryan.

Wednesday, March 9, 2011

DEADLY SPIN - book review

 DEADLY SPIN:  An Insurance Company Insider Speaks Out on How Corporate PR Is Killing Health Care and Deceiving Americans by Wendell Potter.

There is a massive, daily growing number of people who are forced to "go naked" because they cannot afford medical insurance.  If you are completely destitute, Medicaid and state help is available.  However, if you are the working poor (i.e. a couple making more than $19,800 a year in AZ,) you are not eligible for any assistance.  Even if you are earning the medium income of $43,000 (Half the people in AZ make less than $43K) you simply cannot afford even a high-deductible policy that covers OB/delivery care (basic policy cost of $7,000 dollars with a $10,000 deductible and 30% copay after that.)    There are tens of millions of people in this category who work and make too much to get any aid, but can't even begin to afford these virtually worthless policies.  It is increasingly difficult to find a job any more that has "good" health insurance as a benefit.

I am an insider.  I have been a practicing physician since finishing medical school in 1970.  I have been on the board of my group practice pondering how we can manage to continue providing health care insurance as a benefit to our employees at an affordable level.  Still, I was amazed at my naivety regarding the medical insurance industry in this country.  

I knew Cigna, Humana, and the Blues were not my friend, but had NO IDEA as to the extent of their greed and complete absence of ethics, nor of their skillful use of propaganda in achieving their ends that would make the old KGB look like a pack of amateurs.

I heard Wendell Potter testify before congress on CSPAN, watched a long interview with Bill Moyers, and finallly a shorter interview on BookNotes earlier this month.  I just bought the book last week, and read it this past weekend.

Potter, a senior PR manager for Humana and subsequently CIGNA, who "got religion" and crossed over to become the ultimate critic of the same companies for which he managed "spin" for the sole purpose of enriching the pockets of the executives (and himself) through salaries, stock option bonuses, and golden parachutes.   While reading, I was alternatively and/or simultaneously sad, angry, and depressed.  I wish the entire populace would read it.  It was $9.99 on my Kindle, but is available at most libraries.  It is not that long and it is written efficiently and engagingly, so a fast reader can finish it easily on a rainy day at home.

After a brief history of the PR industry, the first 70% or so is specific to the medical insurance companies.  The remainder makes comparisons of the health insurers with Phillip Morris and the other tobacco companies, the coal industry, the oil and petrochemical industries, and other large corporate organizations who spend millions to control congress and to make the general public think that they have honest, good intentions while behaving in the completely opposite manner.

If you don't have the time or inclination to read the book, at least take 35 minutes to listen to Potter speak with Bill Moyers

Saturday, February 5, 2011


 Charles Darwin

James Watson and Frances Crick

Every year there are more and more people and events celebrating the birthday of Charles Darwin, I happen to do that myself most years.  The University of Northern Iowa in fact has a week-long celebration, Darwin Week.

This year however, I would like to see the celebration of a broader significance in the history of biological science.  E. O. Wilson was the first I know of to suggest there were two seminal events in history which opened the doors to our understanding of biology, and in fact, life itself:

Charles Darwin - with his publication of On the Origin of Species in 1859, showed us what happened; that the diversity of life is due to evolution.

Frances Crick and James Watson - with their publication of the double helix structure of DNA in 1952 showed us how it happened, with replication errors - mutations in DNA.

Comparison of these two astounding events provides an illustration not only of animals but also the evolution of scientific endeavor itself.

 Darwin's finches

Darwin's observations and drawings of Finches in the Galapagos were probably a key to the development of the theory of evolution, as he observed that there were distinct populations that were "adapted" for specialized forms of feeding.  Darwin had no laboratory and no graduate students doing his research projects and literature searches.  He was seldom in contact with others involved in his line of thought, and primarily worked in isolation.  His tools were limited to what his eyes could observe of his natural world.  Perhaps most conspicuously, Darwin was in no rush to publicize this theory, probably to avoid the social stigma of publishing heresy, and thereby protecting to some extent his relationship with the pious Mrs Darwin.  Only when word arrived that another biologist was on the verge of publishing a similar theory, did he relent and quickly publish his own writings.

By the time Watson and Crick came along, biological science had "evolved" and was inherently a process carried out by a larger community.  Though Watson and Crick are largely credited with the "discovery" of DNA and the process by which cellular information is transmitted from one generation to another, it was a more complicated, if not absolutely messy, process.

Photograph 51

Rosalind Franklin was working in Sir John Randall's group at King's College in London when she took this X-Ray diffraction image of DNA in 1952, famously known as photograph 51.  She shared it with a colleague, who in turn shared it another associate, Wilkins, who ultimately shared it with James Watson.  Watson and Crick then used that information to construct their now famous model of the "double helix" structure of DNA.  Watson, Crick, and Wilkins were awarded the Nobel Prize (Franklin had by that time died, and so was ineligible for nomination for the prize.)

Rosalind Franklin

So, as Feb 12 approaches and you see some commentary regarding "Darwin Day," you might also remember those that grasped the "what" and showed us the "how" this marvelous diversity of life on earth came to be.