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Disclaimer

The contents of this website are for contemplative purposes only. No medical advice will be given, and emails asking for medical advice will be ignored.

Although patient vignettes are based on my experiences with real individuals, I liberally change details to maintain patient confidentiality.

I also reserve the right to change old postings to correct errors, and to delete comments that include obscene language or that I deem abusive to me or other commentators.  If you are looking for a open mind, I suggest you consult a neurosurgeon.

Katrina Blog Project
Monday
Jan302017

Child Killers

In the first week of the new Congressional session, Senate Republicans took the first step in making good on their promise to gut Obamacare and replace it with... well, who the heck knows.

In typical Washington style, the Republican Senate (no Democrats voted in favor) passed a budget resolution that would defund most of Obamacare’s initiatives, without setting a specific timetable for doing so. In other words, they voted for what they promised without passing an actual law that would make the promise a reality. It was a perfect example of Washington politics: appear to do something without really doing anything.

That doesn’t mean that nothing will happen, though. The House can approve its own bill based on the Senate resolution and then, with a second Senate vote and a reconciliation process, a final bill goes to Trump to sign. What the Senate did last week was to outline their plans for repeal. What they did not do was accomplish anything. Yet.

Since everyone has come to bury Obamacare, I will not praise it. But let’s at least understand that Obamacare is not a thing. There is no Department of Obamacare. There is not a single insurance program developed under the Affordable Care Act (the real name of Obamacare) that was new. The only thing Obamacare did was increase the funding of certain programs, and change some of the regulations for private insurance carriers. No new insurance entities exist. There are so-called Obama insurance plans, but these are just private insurance plans that are adjusted to fit the new regulations and are sold with government subsidies. All of these insurance plans are issued by standard private companies. Nothing new here.

As a doctor, I often encounter patients who wink at me and say, “I bet you hate Obamacare.” Why would I hate Obamacare? Obamacare authorizes more money to pay me, and the payments come from the same companies and organizations who have always paid me. There is nothing for me to dislike. Most of the doctors who dislike Obamacare do so because ideologically they oppose big government programs and don’t want to pay higher taxes. But in the day-to-day practice of medicine, between 2010 and now nothing is different. Same checks, same payers.

I won’t present an ideological argument with about taxes and government here, but I will say that Obamacare changed nothing about the way I practice medicine. The only difference is that there are fewer uninsured. All of the regulations that have changed the way medicine is practiced over the last 10 years have come from a tightening of Medicare law, which is not Obamacare. These changes would have taken effect even if the ADA had never been passed. Nor will they go away if Obamacare is repealed.

Most of the measures the Senate will take to repeal Obamacare are steps I strongly disagree with. Bringing back pre-existing conditions, preventing parents from insuring their own children to the age of 26, and prohibiting insurance companies from imposing lifetime limits -- all of this is manifestly stupid.

But you know what? I don’t care. I’m a doctor, which means I will always be able to get health care. I have nothing to worry about. I can either get my employer to pay for testing I need, or if worst comes to worst, I can ask doctor-friends to help me out. Believe me, I'm good.

It's the people who voted for Donald Trump and have no "in" with doctors who are screwed. They may not realize it yet, but very soon, they will. And I will not feel sorry for them, not anymore. I am tired of feeling sorry for people who choose to sabotage their own lives. Go right ahead, folks. Blow up the ADA. See what happens. I’ll wait. You deserve what you asked for, and you have no idea what you are asking for.

But one aspect of the repeal has me livid -- the cut in funding to the CHIP program. Defunding CHIP was clearly implicated in the Senate vote because, when Democrats proposed an amendment to the resolution to maintain its funding, it was shot down by a nearly unanimous Republican vote. The Republicans mean to kill CHIP. It is one of their political targets.

CHIP stands for Children’s Health Insurance Program. It is a part of Medicaid designed to provide health insurance to poor kids. Its purpose is to extend Medicaid insurance coverage to all children whose parents make too much money to qualify for Medicaid, but not enough to pay for private insurance. Gap insurance for kids, if you will.

And the Republicans, child killers that they are, are trying to shut it down.

As a doctor, I have participated in the CHIP program. I took care of kids first in Louisiana as a CHIP provider and then later when I was in practice in McComb, Mississippi. Like all federal programs, CHIP was not without red tape. But in my experience, it was an excellent program, the kind of thing taxpayers should hope their money is going to.

CHIP is focused on preventative care. To remain in CHIP, parents had to bring their kids in for regular checkups. The kids had to follow immunizations schedules. They had to be screened for hearing and learning disabilities, and doctors had to follow checklists for health monitoring.

As much as, even more than, any other medical program I have participated in, CHIP adhered to American Academy of Pediatrics (AAP) guidelines for child health care. Most insurance programs are fairly weak-kneed about asking doctors to follow state-of-the-art medical standards. But not CHIP. For a doctor to get paid, he or she had to meet AAP standards at each well-child visit. If a doctor refused to follow guidelines, he could be eventually removed from the program.

High standards, preventative care. It is the very thing you want a health program to be.

And for the taxpayer, the view is even better. CHIP provided insurance to kids whose parents made too much money for Medicaid, but not enough to afford private insurance.

Let me state that another way. CHIP is for kids whose parents WORK, but whose parents aren’t making enough to pay for private health insurance.

From where I stood as a medical doctor, CHIP was a pretty good program. It took care of children. It offered a helping hand to parents who were working but not out of poverty yet. And it adhered to medical guidelines for preventative care as established by the American Academy of Pediatrics.

CHIP represents the conservative approach towards government programs. Keep the program narrow and targeted towards groups that would most benefit from the care. Make them modern and in line with the latest thinking in policy (in this case, pediatric medicine). Make them function as a ladder to help people get out of poverty, rather than a crutch.

The last feature, the ladder out of poverty, is crucial here. Poor parents often can’t get jobs with health insurance. And if they manage to get a job, the income from the job makes them ineligible for Medicaid, because in many states any income at all disqualifies families from the program. CHIP allows parents to get jobs and work and not have to worry about their children losing health insurance.

Where is the drawback here?

And yet, Republican leaders have been gunning for CHIP as long as it has been in operation. The standard complaint Republicans voice is that CHIP is federally run, and that individual states should decide for themselves if they want this type of coverage for their citizens. But mostly, I think, they see it as a wedge issue. Working middle class people see poor people get free health care when they have to pay for it, and they get jealous. Attacking CHIP is a way to play to this sense that too many people are getting a free ride.

No one points out the flaw in this argument. The 8 million kids insured by CHIP don’t choose what jobs their parents get. They don’t get to pick their parents, and they can't make money themselves. They are helpless, and therefore without blame for their situation.

The second flaw is thinking that CHIP (and Medicaid, for that matter) are giving “free money” to the poor. Not a dime of CHIP money goes to the poor. You know who gets the money? Me. Nurses. Physical therapists. Pediatricians. Hardworking people who want to take care of kids. Healthcare providers get CHIP money. The patients get nothing but medical care. No money.

So when you oppose a “free ride” for the poor, you are denying money to health care professionals who work hard to help the patients they see. The children are hurt. Their doctors are hurt, when they have to choose between giving free care and abandoning patients who need a doctor.

Today, the 8 million children in CHIP face life without insurance. Some of these kids have serious asthma. Some have cancer. Some have seizures. Some are kids with learning disabilities who need a doctor’s help to remain in school. If these kids lose their health insurance, many of them will unnecessarily suffer, and some of them will die.

And so I salute you, child killers of Washington, DC. Thanks for hurting and killing defenseless children. May the hurt you inflict on others be visited upon you.

On you, Senators, but not on your children. I may be vindictive, but I would never be so cruel as to try to harm a child. To do that, you’d have to be a heartless bastard.

Monday
Jan022017

2016: My Year in Books

Despite all the unfortunate things 2016 brought us (and there have been many), I declare my relationship with the printed word a success. By my count, in 2016 I read 28 books, not counting a few technical medical books, multiple reference books that I haven’t read every word of but have perused heavily, and a large quantity of short stories and essays. I love essays of every form, and would guess that if I could add them all together, the books I have read would make up less than half my total reading for the year.

So, as I said, a good year. Books are a friend to me; I know I have read more books this past year than seen complete movies. The only long form of entertainment that gave books serious competition was football. Probably in 2016 I have seen more complete football games than read books. Maybe.

At any rate, here is the complete list, in the order that I read them:

Bird by Bird, Anne Lamott
All the Light We Cannot See, Anthony Doerr
Hamlet, William Shakespeare
The Now Habit, Neil Fiore, PhD
Revolutionary Road, Richard Yates
Idiot America, Charles P. Pierce
Seven Last Words, James Martin, SJ
Thank You for Smoking, Christopher Buckley
How to Publish Your Book, Jane Friedman
Wherever You Go, There You Are, Jon Kabat-Zinn
10% Happier, Dan Harris
Deep South, Paul Theroux
The Finkler Question, Howard Jacobson
The Art of Fielding, Chad Harbach
Half of a Yellow Sun, Chinamdanda Ngozi Adichie
The Stranger, Albert Camus
Moonwalking with Einstein, Joshua Foer
Talking to Crazy, Mark Goulson, MD
How to Retire with Enough Money, Teresa Ghildarucci
You Are Not So Smart, David McRaney
Lifelong Writing Habit, Chris Fox
Notes from a Small Island, Bill Bryson
Moby-Dick, Herman Melville
The Addictive Brain, Thad A. Polk, Ph.D.
The Revenant, Michael Punke
Writing Tools: 50 Essential Strategies, Roy Peter Clark
Dispatches from Pluto, Richard Grant
The Fellowship of the Ring, J.R.R. Tolkien

For me, the best of this bunch, in no particular order (because I am not the type that ranks everything -- I think equally highly of many books), are Moby-Dick, All the Light We Cannot See, Revolutionary Road, and of course Hamlet.

Moby-Dick was a re-read -- I first read it one summer during high school. It was much better than I remember. Moby Dick, though very long, has to be read patiently. Melville’s prose is not easy to get through, but despite his long-windedness he never wastes a word. It is possible to misunderstand an entire chapter for want of a single sentence, or even a single word. That was the surprise of my Moby-Dick experience, that Melville is so precise. Like the true master he is, he means what he says and says nothing more than he means. My advice: Take it slowly! Rushing through Moby-Dick makes about as much sense as taking Christmas dinner standing up with a 5 minute egg timer and a shovel. You take it at the pace it wants to come, and it rewards that patience with vast treasures.

 All the Light We Cannot See was a luminous joy. Because it was unexpected: I had never heard of Anthony Doerr before, and yet I found that his tale of a blind girl eluding the Nazis in World War II France, despite the dark setting, lightened my heart. Perfect winter reading.

I would also like to acknowledge Dispatches from Pluto, a memoir of a British writer’s experience of moving to the Mississippi Delta. It was funny, and, as a Mississippi resident, I can vouch for its truth.

Finally, as a writer let me salute Bird by Bird, a book that most non-writers will never read, because it is about the craft of writing. Lamott’s memoir/advice book on the art of writing is funny, joyful, harrowing, and most of all hopeful. It put a spark in my pen (or keyboard) this year, and for this I am grateful to Ms. Lamott, a rare writer who knows how to be both harrowing and hilarious at the same time.

I look forward to 2017, and another 30 or so books. I have to finish the last two books of Lord of the Rings (another re-reading from childhood), and beyond that, my nightstand runneth over. Waiting to be read are, among others, My Brilliant Friend, When Breath Becomes Air, The Long Loneliness, The Prize, many splendid things by Michael Chabon, Marilynn Robinson's Housekeeping, Italo Calvino's Invisible Cities, and who knows what surprises life will bring me.

My eyes are ready to behold the world.

Have a happy New Year, and read well and often.

Sunday
Dec182016

Handel's Messiah and the 142

Here is a something to think about as Christmas comes: the number 142.

Let me explain.

George Fridrich Handel, though born in Germany, is best remembered for the many years he lived in England, writing music for a series of British monarchs and for English audiences. Trained in Germany and Italy, Handel was a master of Baroque art forms, and was the first to introduce the ideas of Italian masters to British audiences. For many decades, he enjoyed great success. But by the 1740s, British music tastes had changed, and the popularity of Italian opera, Handel's specialty, began to wane in favor of works with English lyrics.

After several failed operas in Italian, Handel was at a low point in his career. His interest turned to the oratorio, a musical form that involved the setting of prose or poetry to music, and, in Handel's case, allowed for the adaptation of sacred scripture, translated into English, to classical and operatic musical styles. Handel was hoping that oratorios in English and the familiarity of the Bible would appeal to English general audiences.

His friend Charles Jennens, a well-known librettist, assembled and edited the text of the Messiah especially for Handel, in the hopes that a successful oraratio on the life of Jesus Christ would improve Handel's fortunes. However Handel, perhaps feeling he should not personally benefit from such a holy subject, had his own idea. He would donate the proceeds to charity.

At first, Handel, busy with other projects, put Jennens off, but in the late summer of 1741 he composed the masterpiece with astonishing speed. In a mere 24 days, he had completely scored 53 movements, including the immortal Hallalujah Chorus.

After some delay, Handel decided to perform Messiah for the first time in Dublin in 1742. No one is certain why he made the decision to open in Dublin instead of his hometown of London. Possibly, it was because he had promised the Duke of Devonshire, who was serving as Lord Lieutenant of Ireland, a series of concerts there. However, an equally plausible reason was that Church of England clergy were resistant to orotorios based on the Bible, because they believed sacred scripture should never be used as a form of entertainment. In fact, Handel's previous attempt at a biblically based oratorio, Israel in Egypt (1739), failed under withering attacks from the British clergy.

Handel may have sensed that Irish audiences, being somewhat removed from the reach of conservative Anglican thinking and more in line with Catholic tradition, would be more receptive. The Catholic Church, through its veneration of the Saints and its tradition of live Nativity scenes, was much more accustomed to dramatizations of sacred stories.

But for whatever reason, the Messiah premiered in Dublin, Ireland, on April 13, 1742, and would not appear in London for another year (where it was, confirming Handel's instincts, less well received).

In Dublin, the Messiah was a smash hit, and 700 people packed the New Music Hall to hear the opening performance. So many advance tickets were sold that the concert managers asked men to leave their swords at home and for women not to wear hoops in their skirts so they could pack more people onto the benches.

For one of the work's most famous movements, "He was despised," Handel chose Susanna Cibber, an actress who had been disgraced by a London sex scandal. A clergyman in the audience was so moved by her performance that he leapt to his feet at the end of the movement and cried out, "Woman, for this be all thy sins forgiven thee!"

And in this vein of forgiveness, we come to the number 142.

The Messiah opening netted £400 on opening night, and true to his word, Handel distributed the proceeds to three charities -- two hospitals, and a debtor's prison. And so in April, 1742, 142 people were released from an Irish debtor's prison when Handel paid off their debts. Freedom for a song.

Perhaps, when you hear the Hallelujah Chorus or any part of the Messiah this Christmas week, you may think of forgiveness, and of the number 142.

Imagine: The Hallelujah Chorus bought the freedom of 142 Irish debtors. As if you didn't have enough reason to love it already.

Why did Handel do it? Perhaps we can see the answer in Handel's own words. After completing the Hallelujah Chorus, he told a friend, "I did think I did see all Heaven before me, and the great God himself."

If this were a visual work I might close with a recorded section of the Messiah, but since I am restricted to words alone, let us close with a few exerpts from Jennen's famous libretto.

From Part I:

For unto us a Child is born, unto us a Son is given,
and the government shall be upon His shoulder;
and His name shall be called,
Wonderful, Counsellor, the Mighty God,
the Everlasting Father, the Prince of Peace.
(Isaiah 9:6)

He shall feed His flock like a shepherd;
and He shall gather the lambs with His arm,
and carry them in His bosom,
and gently lead those that are with young.
(Isaiah 40:11)

Come unto Him, all ye that labour,
come unto Him that are heavy laden,
and He will give you rest.
Take His yoke upon you, and learn of Him,
for He is meek and lowly of heart,
and ye shall find rest unto your souls.
(St. Matthew 11:28-29)

From Part II:

He was despised and rejected of men,
a man of sorrows and acquainted with grief.
(Isaiah 53:3)

From Part II: Hallelujah Chorus:

Hallelujah: for the Lord God Omnipotent reigneth.
(Revelation 19:6)

The kingdom of this world is become the kingdom of our Lord, and of His Christ;
and He shall reign for ever and ever.
(Revelation 11:15)

King of Kings, and Lord of Lords.
(Revelation 19:16)

From Part III:

O death, where is thy sting?
O grave, where is thy victory?
The sting of death is sin, and the strength of sin is the law.
(1Corinthians 15:55-56)

And finally, from Part III, my favorite, the Great Amen:

Worthy is the Lamb that was slain,
and hath redeemed us to God by His blood,
to receive power, and riches, and wisdom,
and strength, and honour, and glory, and blessing.
Blessing and honour, glory and power, be unto Him
that sitteth upon the throne, and unto the Lamb, for ever and ever.

Amen.
(Revelation 5:12-14)

 

Monday
Nov142016

Post-Election Reading List

When the going gets tough, the tough get reading.

Here are a few books I've read recently that help make sense of the recent election.

Deep South, by Paul Theroux. A somewhat cantankerous but honest assessment of poverty in rural America. It helped me appreciate a part of America that is everywhere but poorly understood.

Hillbilly Elegy by J.D. Vance. The moderate-conservative answer to What's Wrong with Kansas. A look at the suffering in the rust belt with sympathy that is not, for a change, also uppity. For a taste of this content, Vance wrote a post-election essay for the New York Times that offers a taste of his worldview.

Dispatches from Pluto,by Richard Grant. A look at the poorest of the poor in America, the Mississippi Delta, from the viewpoint of an Englishman-cum-New Yorker. And with a kind eye and even a sense of joy, I might add.

The Righteous Mind, by Jonathan Haidt. An examination of the differences between right and left wing psychology. I found the most eye-opening aspect of Haidt's research his discovery that one of the traits conservatives have in common that liberals do not is the importance of the sacred. In Haidt's view, conservatives are horrified by the abandonment of respect for sacred things (like flags and prayer) in liberal life.

Thinking, Fast and Slow, by Daniel Kahneman. Although this book is not about politics, it may be the most important book about human thinking written in the 21st century. A summary of Kahneman's Nobel Prize winning research, it looks at how humans make decisions, and how our tendency is to make decisions based on emotions and then back them up with facts, instead of the other way around. In Kahneman's thinking, the gut feeling almost always wins.

The Unwinding, by George Packer. A look at how the American system, in the wake of the 2007 financial crisis, has failed middle class Americans. Packer's view is that the disappearance of traditional institutions that supported the American Dream has resulted in concentration of wealth and the erosion of much of American cultural life.The Unwinding won the 2013 National Book Award for Non-fiction.

Wednesday
Nov092016

Clinton v. Trump

A few rough thoughts about our election, and Donald Trump, who will be our next president.

  1. I wanted Clinton to win, mainly because I disliked Trump so much. But I voted against Hillary in 2008 because I didn't want the wife of a former president becoming president herself. The presidency isn't a prize to be passed among a small number of elite families. Was Chelsea to be next? Michelle Obama? But we didn't do much better with Trump, choosing a white male billionaire celebrity. That isn't exactly breaking the concept of elitism.
  2. People in the country hate the government. Many see the government as a mechanism for funneling money and power to the super-rich. In that respect I agree. I just think the solution is not to turn the apple cart over and set it on fire.
  3. People hate Obamacare not because it exists (though this is true of Republican elites) but because it doesn't work for them. One thing I think I heard loudly in the run up to the election is that people are upset that Obamacare has not solved their health insurance problems. I think they want help in health care, but they want effective help, not a bureaucratic dog and pony show.
  4. The problem the average American faces is a lack of hope. People work without any hope of seeing a better life. People are angrier about this than anything. Millions of people work jobs in fast food, driving, lawn care, and have no hope of doing anything else. This is a sad thing, and neither political party gives a damn.
  5. Barack Obama is disliked by millions of poor whites not so much because of racism (although I do not doubt that factors in) but because he represents globalism. As do the Clintons. Poor Americans have seen industry disappear in this country, and they watch as technology takes their lives away. Uber puts cabbies out of work. Computer systems have elminated the jobs of transcriptionists, secretaries, file clerks, librarians, and many more and replaced them with nothing.
  6. Technology ploughs along, destroying lives in the process, most all of them poor. Self-driving cars will end the careers of millions of employed drivers. Consider that one of the richest companies in America, Facebook, is worth billions and only has a few hundred employees. This is typical of tech companies. They generate a huge amount of money for a small number of lucky people, while putting regular people out of work.
  7. The key to this election was encapsulated in Hillary Clinton's problems with the West Virginia miners. These people have been put out of work by technology, and it was clear that Clinton had done little or no thinking about how to assure them that they would be able to make a living. She just offered more education, which to them means student loan debt and not necessarily better prospects.
  8. The great fault of liberal globalism is lack of religion. To people left out of globalism, liberalism feels like an atheistic denial of human values and God. It also feels like an abandonment of American values. To me, this makes some sense. You can't open all borders and have complete exchange of ideas without losing something of your own identity. Of your own religion. There has to be a balance between the two. Right now, there is nothing in politics designed to protect the culture and values of people not part of the technological revolution. That is, rural whites and poor blacks.
  9. To people who accuse Trump supporters of being sexist, racist, xenophobic, and small-minded, I agree with you up to a point. But people resort to these vices when they are afraid. What no one has wanted to do is ask where the fear is coming from.
  10. I fear Donald Trump is not a good vessel for this energy for change. He is not, I think, capable of tearing down Washington and erecting something useful in its place. Maybe he can, but I don't think so. We could be in for a hard time.
  11. Stop the crap about running to Canada. The reason the Democratic party keeps failing is because when it gets beaten it doesn't bind together. Everyone just runs off and hides. Ideas that are worth fighting for when you are ahead are worth fighting for when you are behind. Or they weren't ever ideas in the first place.
  12. Forget about the damn emails. There will be a lot of soul-searching and wailing about this issue, but I don't think it had much to do with it. Except to the extent that the emails revealed a Clinton who thought she was too big for the rules. She could have saved herself from the issue by handling it differently, but Trump would have found something else to pound her with. Clinton excudes a sense of being out of touch with the common people. Even I can see it, and I'm pretty elitist myself. I can't image her telling an off-color joke, drinking beers at a bar, pumping her own gas. I know Trump has similar problems, but somehow these limitations stick to her much more than to him. It is probably related to her association with globalism, which makes her an unsympathetic figure.
  13. Finally, I confess to the sin of hubris. There was way too much hubris on the Clinton side. Who is to say that educated liberals really know best? Who is to say voters are too dumb to know what they want? The people chose. They chose Trump by the tens of millions. Is it really my place to judge them as stupid, or racist, or wrong?
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