Monetizing Washington

http://www.washingtonpost.com/business/2013/12/27/496c19d0-6c05-11e3-a523-fe73f0ff6b8d_story.html?wpisrc=emailtoafriend


Steven Pearlstein has written a piece in the Washington Post which has great resonance for the Phantom. The link is above. Hopefully, it will work. If it doesn't--it's the Washington Post , 12/28/13, "The Insider's Game."

It is simply a depiction of how living in the Washington, DC metro area in the 1950's and 1960's was a much different experience: Washington was still a very Southern town and while it was a very broadly comfortable place to live, there were few mansions and pervasive efforts were made to discourage conspicuous consumption. 

The prevailing notion was: "We are here to serve. We do not want to appear to be getting rich by doing the nation's work. Big houses, expensive cars would suggest corruption. Nobody should be getting rich doing government work."

Pearlstein begins his story with an anecdote about starting work at the Post and being confronted by an editor who had seen notice of Pearlstein's purchase of his home for what struck the editor as an unseemly amount of money.  That story struck the Phantom as a bit over the top, but only because the Phantom, by the time he left Washington, was imbued with the notion that houses in Washington were bought and sold for astonishing amounts. 

But, the major change in the ethos, which Pearlstein documents so well, is the shift from people who were interested in the job, not the money. They were just five or ten years out of the army, and in the army you didn't ask how much an assignment paid, you took a job because it was an important job, a challenging responsibility, but you didn't ask, didn't care, how much it paid. 

Congressmen, doctors, airplane pilots, judges, heads of agencies like the SEC, federal workers, teachers all lived in the same modest development. The houses had been built in the mid 1950's, and they had enough room, but were by no means McMansions, and most importantly, they were close in to downtown, so you could get to the government buildings where you worked by car, or by bus, with great dispatch.

When kids talked about parents, they never said, "Oh, her father made a fortune in real estate." They might say, "Oh, her father is a Congressman."

Pearlstein has written what in college would have been called an "ethnograph," outlining the values by which that town once operated and how those values changed and why.

It's worth reading.

Homeland--the TV show--the Demise

Watching this season of "Homeland" was like seeing a new girlfriend unravel before your eyes. What had once seemed so promising, exciting and wonderful fell apart, bit by bit until you find yourself just wanting out.

The best character in the series, Brody, conflicted, vacillating, fascinating as a chameleon, is offed.

Episode after episode of the daughter, quivering lipped Dana, is inflicted upon you, while Brody is nowhere to be seen. With him off the screen, the action creaks to a halt.
Even Carrie, who has been fun to watch, dissolves into a helpless object who has to be rescued.

And the great surprise, which is nothing more than  reprise of The Spy Who Came in from the Cold, in which it turns out the disaffected spy (Carrie) who has apparently rejected her old friends at the CIA, was actually playing at disaffection to get close to the head of the Iranian spy agency--that surprise is launched mostly off stage with not enough hints at what was going on to make the game between viewer and writer a fair game.

But the whole premise, that installing a new CIA run mole as the head of the Iranian spy agency would result in the Iranian government agreeing to giving up its nuclear arms project and agreeing to international inspections is absurd:  Since when does a spy agency decide on a major policy shift like abandoning a nuclear weapons program? 

The writers of Homeland were so in thrall with The Spy Who Came in from the Cold they had to kill off Brody at the end, just as Le Carre killed off his protagonist in the end, they kill off Brody. (At least they didn't have Carrie captured and killed as well.)

Any Le Carre aficionado can see in Saul's pursuit of the Iranian, Smiley's pursuit of Karla. There is even the adulterous wife of Smiley reflected in Saul's wife, who pursue outside business with someone who turns out to be an Isralei spy, who could have planted the bug in Saul's computer during any of his trysts with the wife, but somehow has to sneak back in when she's not home and narrowly avoid been discovered--dramatic tension trumps tight plotting every time in this series. 

And then there is the Tale of Two Cities aspect of Brody going off willingly to his execution doing a far, far better thing than he has ever done before. Plueeeze,

And what was that pathetic scene with Carrie climbing the fence to lock eyes with Brody as his own eyes are popping out of his head, as the rope tightens.

Why did Carrie want to be present for Brody's hanging? Who would want to witness her true love swinging from the end of a rope?This makes no sense, emotionally, rationally--just another instance of the writers saying, "How can we ratchet up the conflict and intensity here--even if it makes no sense whatsoever. I know, we can have Carrie run naked into the crowd, a streaker to distract the hangmen, but no, they hang him any way.


At least the hanging scenes in "The Killing" and In Cold Blood served understandable purposes--in the case of "The Killing", the brutality directed at an innocent man, and In Cold Blood, the lack of expiation from seeing the killers, who were clearly guilty of a brutal murder, hanged. 

At least "The Killing" has been renewed by Netflix, so we do not have to lose Sarah and Holder, the best pair since Nick and Nora. Of course, how they are going to extract Sarah from the murder of her boss/serial murderer/lover/detective honcho is anyone's guess. Perhaps they can call the "Homeland writers" for a few tips on implausible but really intense solutions to this problem.  I know, a drone nukes the scene of Sarah's murderous attack, destroying all evidence. But ultimately, Sarah has to explain what happened to her missing boss and the Seattle police decide Holder must have killed her boss in a jealous rage;  they drag off Holder to hang him for the murder and Sarah must watch the execution. 

All in all, it was just one of those doomed affairs. That fetching beauty who was "Homeland"  was never really what you thought she was. She was pretty, and caught your eye, but as time went on, you found she just could not sustain it. She just wasn't bright enough. All flash, no bang.

Oh Sister! Dylan, Old Mortality, Oh, Brother, Where Art Thou?

Oh sister when I come to lie in your arms
You should not treat me like a stranger
Our Father would not like the way that you act
And you must realize the danger.

Oh sister am I not a brother to you
And one deserving of affection ?
And is our purpose not the same on this earth
To love and follow His direction ?

We grew up together
From the cradle to the grave
We died and were reborn
And then mysteriously saved.

Oh sister when I come to knock on your door
Don't turn away you'll create sorrow
Time is an ocean but it ends at the shore
You may not see me tomorrow.
--Bob Dylan

The Phantom had never heard Bob Dylan's "Oh Sister" until Maud alluded to it. Discovering a Dylan album and work is akin to the recent news a trove of paintings, apparently stolen by the Nazis, or hidden from them or simply lost was discovered in good condition.

What joy.

Accompanied by Emmy Lou Harris, it's a wonderful piece of music, beyond the words. According to Wikipedia, it was a favorite on concert tours, but the album was released in 1976, when the Phantom was not available for concert going and there was no iTunes, so the Phantom had been unaware of it, until Ms. Maud cited it for its relevance to a discussion of the pressure mortality puts on living.

What is intriguing about this song is the Christian imagery. There is also the profound ambiguity of what he is talking about, not unusual in Dylan, but this one confuses the Phantom. For one thing, it does echo, "To A Coy Mistress,"  which is an effort to persuade a desired lover into bed.  But this is pretty clearly addressed to a sister, and not a sister in the sense a Black man might call an unrelated Black woman, "sister."  This is a woman he grew up with, presumably a biologic sister. And he wants to lie in her arms and he wants "affection."  None of this means he is talking about sex, but the ambiguity lays across the big brass bed.   On the other hand, he says our Father (capitalized) would want her to show him affection, and presumably, our Father is not a great fan of incest.

On the other hand, perhaps the Phantom has sex on the mind when, in fact, Dylan is talking about another sort of love entirely, the love we ought to show our neighbor, our family.

The internet is rife with comments about this song and the range of interpretations is broad, often derived from what fans know about Dylan, his love life, and everyone fro Joan Baez to Emmy Lou is mentioned. 

Whatever the words mean, it's a lovely song, peculiar, but lovely.

Life's Too Short

John Singer Sargent at the Boston Museum of Fine Arts is worth the 45 minute C&J bus ride. 

As is true of Van Gogh, Sargent cannot be appreciated in prints. The painting shown above is not really close to the original, in which the hats are nearly white and the facial expression on the wife is priceless.

As the sound of the winged chariot drawing near becomes more audible, the Phantom has decided one must make time for things which really astonish. For some, that is travel. For some, that is jumping out of an airplane, for some, it is simply learning to knit.

For the Phantom, it includes standing in front of people who have lived before him, now gone, who left behind evidence of the exuberance of mastery--Van Gogh, Picasso, and now, newly discovered, John Singer Sargent.  The Currier Museum in Manchester is wonderful, and a manageable size, but this exhibition of JSS is stunning. 

The final episode of Band of Brothers is called "Points" and it follows the soldiers of Company E after Victory in Europe.  They realize they have got past the ever present dangers of combat and they have survived. They start thinking about what is next in life. They are young, so what they look forward to is meeting women, having a family, starting a career, all of which are so much more attractive now that they've experienced combat. They really do know every day is a gift not to be squandered. The Phantom got a little of this lesson on the wards of Memorial Sloan Kettering Hospital for Cancer and Allied Disease during his internship and residency, where the mortality rate among the patients exceeded the mortality rate of E Company.

As we pass through the decades, especially when you get into the 6th decade, you acquire the same sense of joy and wonder and you know if you don't get on with it now, you may not get another chance. 

It's Marvell's winged chariot hurrying near--it's coming for all of us. 

Medicine: The Calling Becomes a Job

The Phantom recently decided he needed to change jobs. 
Again.
For nearly three decades the Phantom had practiced medicine as a solo practitioner, with all the risks of a small business owner:  signing a lease which was essentially a mortgage without the benefits of ownership, for half a million dollars, meeting a payroll, keeping track of all the licenses and government regulations for disposal of medical wastes, keeping up a computer system to electronically bill Medicare and other insurance companies--a requirement, not an option--managing the upkeep of office equipment, making decisions about whether or not to buy a sonogram for the office--the cost of a new car which had to be paid off over time, calculating the reimbursement vs the monthly cost of upkeep and payment. Finally, when the man from the office building in which he rented space showed up in his office, wearing a leather jacket, looking like a thug with his gold necklace and diamond stud earring, and uttering the words, "And now we have to talk about your new lease. You know, this part of Chevy Chase has become Rodeo Drive East," the Phantom knew it was time to close shop.

Luckily, there was a job opening for his specialty in a town which was  gorgeous and alluring along the New Hampshire seacoast, and the office was brand new, a block from the hospital, a twelve minute commute from the new house the Phantom found just three miles from the ocean. The Phantom and his wife packed up, sold the house in which they had raised their kids, bid good-bye to their bewildered friends and neighbors and moved up to New Hampshire. 

Symbolically, the day they were to start out, their 13 year old dog died. So, the final remnant of the life they had known in Maryland, running the dog along the Potomac river towpath, was put to rest and off they went, like so many other economic refugees before them, pilgrims to the Promised Land of New Hampshire.

And New Hampshire did not disappoint. Within walking distance of their home was everything they needed, hardware store, dry cleaners, pharmacies, restaurants, gas stations, auto repair shop, all the convenience of a New York City neighborhood in a small New England town. And of course, there was the ocean.

Bidding good bye to two thousand patients and to two hundred colleagues was not easy--it was like breaking up with 2000 girlfriends--"It's not you. It's me." But soon enough there were new patients and new colleagues and the people were fun and wonderful.

But all good things must come to an end: The job was with a for profit, corporate medical system and after five years, the emphasis became, most emphatically, on the profit and the medical system part was almost forgotten. The corporate offices were far away, in Virginia.  

And in a sequence which is being played out across the country, the typical pattern is: You are hired at the highest salary you will ever get from the new employer, and eventually, the screws are tightened, the salary gets converted to an "eat what you kill" design, so you are left with the prospect of either racing past patients or substantially reducing your income. Every minute you spend with a patient is a dollar less for you to pay your bills.

What to do? What doctors are doing now with regularity: look for another new job, get the two year salary and when that term ends, look again. Hope you don't have to move your home. Hope you can simply move among the various employers.

In New Hampshire, that prospect is limited by "non compete" clauses which forbid the doctor from practicing within 15 to 20 miles of his former office, but a 20 mile commute can be managed.

When the Phantom took his new job, his wife was sullen and uncharacteristically quiet. She finally fessed up to the problem: The Phantom was leaving the biggest hospital in the seacoast, a gleaming, newly renovated edifice. She had been the wife of a doctor who everyone in town seemed to know. The women who sing in her chorus had, in surprising numbers, consulted him or knew someone who had. She felt, as she had in Maryland, she and he were part of a community, valued and respected.  His new job was in a town across the border in Massachusetts, twenty miles away, where they would never be known. The hospital there was shabby compared to the New Hampshire digs, although the doctors' office building was new. But the local esteem of friends and neighbors would not be there. They would know nobody in that community. 

It would just be a job now. You commute in, drive home and nobody would even know who you are. You could be working for Liberty Mutual or Sig Sauer or Westinghouse or any of a range of corporations which have no emotional resonance in the community in which you live. 

Medicine had been converted from a way of life, from a calling which enobles,  to just another job. Her status in our new community would change.  Her husband would no longer be locally famous and respected. He's just a salary man now.

Of course she had had a stellar career of her own, commuting back and forth to Washington, DC, flying around the country. She did not need her husband's status for the sake of her own sense of self worth.  She had plenty of success and satisfaction from her career before she retired. But now, watching her husband, move from an upscale practice in an upscale area to a town which looked shabby and a little desperate, it felt like a slide toward decline, even if she stayed in her beloved New Hampshire home.

For the Phantom, things did not look that way. He could see the new reality of medical practice. It wasn't just old doctors crawling off to economically deprived areas to die. The idea of a "glamour practice" had long ago lost its allure. The Park Avenue practices he and his wife had seen in New York City in the 1970's had all vanished into institutions--over 90% of doctors are now employees, working for big groups, institutions, hospitals, corporations. They do not build up practices by attracting the rich and famous and watching the hoi polloi follow into the waiting rooms. They do not revel in being named a "best doctor" by the local magazines, and buying a framed copy of the article to post in the waiting room. They go to work, see the patients caught up in the corporate net, referred by other doctors who refer not because they value the talents or the glamour of the consultant but because their corporate bosses command: Use this guy. He's our employee. The money comes back to us.

This is actually a system which can result in great efficiencies and even in better quality. When the Phantom became an employee, he got his ultrasound machine and all sorts of other equipment which he could never afford as a solo practitioner and he was able to improve the quality of care for his patients, while seeing more of them.  He was able to go to two medical conventions a year, and these are not boondogles. These conventions are where vital information gets exchanged, critically evaluated and digested. They are exhausting, but since the government required doctors to keep up continuing medical education, it's been worth going to these events.

So what it means to be a doctor has changed.  And maybe that's not so bad. It means well trained doctors are willing to go to humble towns where medical care is needed because that's where the need and the dollars are. It strips ego away from the practice of medicine. That old idea of a glamour practice was, in its own ways a corruption. It was about the ego of the doctor. If a doctor says to himself, or to others, " I went to Harvard Medical School, trained at Columbia and Hopkins. I treat the rich and famous and I am rich and famous.And this is success in medicine,"   is that such a good mindset we need to mourn its passing? Doctor to the stars. What ever happened to the humble country doctor?

And the fact is, for the most part, the doctor was never really admitted to the society of the fast set. As in the world of Downton Abbey, the doctor was admitted to the mansion as a workman, not as an equal. He simply did not have enough money or class to be "one of us."

American doctors now  are more like the assembly line workers in Detroit. We are part of a big, efficient system which puts out a product people want and we get our salaries and benefits and we punch the clock and we go home. We are no longer defined by our jobs. We may have prestige because we command relatively large pay checks (although these have diminished substantially, $100-200,000 is still enough to keep you in the upper middle class.) But we do not have esteem. Esteem is what attaches to the individual. Prestige attaches to the group. But it's no longer, "Good ol' doc Phantom. He delivered every one of us into the world, and he eased our passing out of it." 

Norman Rockwell is dead.

Long live Henry Ford.

Truth or Consequences in American Medicine, 21st Century Version

The New York Times has been a source of wonder and amusement to the Phantom lately, with regard to medical stories:
1. November 23:  Dr. Elizabeth Stier, a faculty member of the division of Obstetrics and Gynecology at Boston Medical Center, who is doing research on anal carcinoma, a disease which affects both men and women,  was recently notified by the American Board of Obstetrics and Gynecology they will decertify her as a board certified gynecologist if she persists in treating men,  as part of her research study. In explaining the board's stance, Dr. Kenneth Noller, the board's director of evaluation, provided a stunning explanation: "There were plenty of other doctors available to provide the HIV-related procedures that some gynecologists had been performing on men." If Dr. Stier persists treating patients regardless of their gender,  she will be defrocked, excommunicated from the club of certified gynecologists and possibly condemned to wander for all eternity in darkness. The board has not decided about wandering in the darkness yet.

2.November 24:  In the business section of the NY Times an article about the marketing of testosterone therapy directly to the public. Pictured and quoted in the story is Dr. Harry Fisch, a urologist, "who likes to say a man's testosterone level is 'the dipstick' of his health," and being a urologist, one might expect he might know about dipsticks, but he clearly does not know about testosterone.

  Fortunately, the Times has found someone to quote who may actually know of what she speaks, from  Georgetown School of Medicine, who, commenting on the advertising blitz said, "Do you feel tired after dinner?  Depends on how long after dinner. We all do eventually. It's called sleep."  

The article focused not on the truths we think we know about testosterone deficit as a disease in men, but on the marketing, the income derived--$2 billion dollars  in 2012, up from $324 million ten years earlier, after a $107 advertizing blitz by the drug makers, a nice return on investment. Of course the business types at the Times were either not interested or not qualified to judge anything about the basic truth of whether or not men are being treated for a real disease, i.e., for a true deficiency state,  or simply being sold snake oil. All that matters to the drug makers and the MBA types is the game: The FDA forbids the drug companies from trying to sell testosterone to men who are not truly deficient, but it does not forbid medical doctors like Dr. Fisch from becoming the pitch men for the product. If Dr. Fisch or a whole legion of like minded doctors want to prescribe Androgel, well, that's not the drug company's fault. They can't stop people from wanting their product. They just collect the money.

Any doctor can say anything he wants about testosterone, unless of course he is a board certified gynecologist, in which case he (or she) may be de certified and condemned to wander in darkness for all eternity.

3.November 24:  Mary Lou Jepsen, writing in the NYT Review, tells her harrowing tale of having a pituitary tumor which was misdiagnosed and mistreated, "only partly because of the shortage of endocrinologists, doctors who specialize in the hormonal systems." 

She tells us, "Without the ability to fine-tune my hormones and neurochemicals I believe I would have been trapped as a near-imbecile, wheelchair-bound, in my mother's basement for an abbreviated and miserable adult life. But with this ability, I have reached the top of my field. Still, the health care system hinders my acces to the chemicals I need to live. I am far from alone in this situation. It's time we changed the system."

Now, the Phantom has a special affection for endocrinologists, but he was disquieted when he got to the part where Ms. Jepsen says, "This all changed when I finally found a doctor to work with me to reconstruct my personality and my health by tuning combinations and doses of these powerful chemicals." 

Oh, oh, oh. And what kind of "endocrinologist" could do this? The Phantom lives in New Hampshire, where there are things called "naturopaths" who live under bridges and prescribe all sorts of things--eye of newt, testosterone, clomiphene--and they usually sell these out of the snake oil chest in their offices at substantial profit, and oh, my, my.  If truth is the first casualty of war, then truth is also the first casualty of the desire for financial profit.

The editors of the NY Times, did not call the Phantom for his opinion about the medical history Ms. Jepsen provided. The Phantom would have said, "Whatever this unfortunate lady had, it is dead certain what made her better was not any fine tuning of hormones and neurotransmitters."

                                                                  ***

Here's a truth for the blogging public: There is, in fact, a huge revolution in American medicine and it has nothing to do with endocrinology, or testosterone or urology or gynecologists treating males with anal cancer, or with any science at all. It is contained in the observation that somewhere north of 90% of American doctors are now employees, file W-2 forms, and work for large corporations, "voluntary" hospitals, incorporated medical groups, the government or academic institutions. 

That, more than any scientific breakthrough, more than unraveling the human genome, more than any drug, more than startling advances in surgery (like laporoscopy) or in imaging (MRI's, ultrasounds) or in "personalized medicine," and certainly that, more than Obamacare,  has in fact, "depersonalized" medicine.

If your doctor is an employee, he likely has in his (or her) contract a clause which explicitly states that any patient he sees, (i.e., you) is the property of the corporation/ employer,  not the physician. That means, among other things, if the doctor leaves the practice he may be forbidden from "soliciting" you to be his patient.  He may run away from you in terror, should you track him down and show up in his new waiting room, for fear his former employers will direct their large in house corporate lawyers to drag him into court for "solicitation."  (And we are not talking about a misdemeanor, and a quick mug shot here.) He can only treat you if you manage to track him down all by yourself, which, given restrictive "non compete" clauses in his contract,  may mean he cannot practice any where within 20 miles of his current location. 

Think about that a little. 
Your doctor and you are not in the room alone. 

What's Eating American Healthcare? Obamacare Is The Least of It

An Effective Leader

If a hurricane followed by twelve tornadoes ripped through the state of New Hampshire tomorrow, some people would blame it on Obamacare.

The fact is, medical care is changing in ways which are not (yet) apparent to the consumers of health care, and only a small proportion of those changes is going to be affected by Obamacare.

Which is not to say the health insurance industry has not been a major force in the changes. Health insurance, the money people have driven doctors off the field over the past ten years. Nationwide only about 10% of doctors are self employed, independent, hang-out-your-shingle free market, Ayn Rand control your own destiny figures any more.

Most doctors are employees of either large corporations (hospitals, Kaiser type organization, commercial companies like Hospital Corporation of America, or large group practices). 

Insurance companies, and to a much less extent, Medicare, have so reduced payments to doctors, the vast majority found they could no longer pay their rent, meet their payroll and earn a living, so they flocked to employed status.

What they found when they arrived is that their new masters demanded more and more patients seen per unit of time.  

Administrators began to break down the tasks doctors do during their day, and dividing up these tasks to be done by high school graduates. Need a skin biopsy--have the dermatology tech do that. Costs less.  Need a stress test, a chest tube, almost any in office procedure, hire a tech. Need a visit to adjust your insulin doses?  A certified diabetes educator, might be a dietician, can do that. Need your coumadin dose adjusted, a nurse can do that.

What has been left to the doctors, the administrators argue is the stuff only the most expensive member of the team can do--read the X ray, listen to the history and order the diagnostic tests and the medication or the referral.

So far, all this, it may well be argued, increases efficiency and decreases costs.

Except when it doesn't:  Nurse practitioner and physician assistants now see patients for things like possible hyperthyroidism, angina, inflammatory bowel disease, multiple sclerosis, Lyme disease, peripheral vascular disease, and they often order the wrong or most expensive tests which means we are in the position of being penny wise, (cheaper visit) but pound foolish (unnecessary referral to a consultant $500, $4000 MRI, visit to the ER $1000).

"Medicine is too important to be left in the hands of doctors," was the jarring line of the 1970's. It was very punchy and anti authoritarian and it was widely quoted, almost a mantra.

Trouble is, that line has turned into a policy. Now the doctors no longer have much at all to say about how medicine is delivered.

It hasn't been and won't be pretty.

Yesterday, the Phantom met with the CEO of his hospital and a number of administrators from the corporation which runs the practices connected to the hospital.  These practices "feed" the hospital system. They send patients, laboratory, radiology referrals to the hospital. They, in business terms, bring the customers through the front doors.

 The CEO  said the purpose of the meeting was to open communication between the doctors and the administration. When the doctors started talking about the problems the practices were having, about the loss of critical doctors, about why they could no longer refer patients to the hospital, or send them to the emergency room,  the CEO of the hospital said she did not want to hear about those problems. 

She had problems of her own. She had not been able to meet her budget for the past 3 years. The doctors had been trying to tell her about why they were sending fewer and fewer patients across the street to the hospital, but she did not want to hear about any of that, she said. The problems in the practices across the street referring to her hospital were not her problems, she said. The practices belonged to another administrator. All she cared about was the hospital.

"So, if you manufacture cars, and the dealerships which sell your cars all over the country are closing down, that doesn't bother you?" someone asked. "All you care about is what is happening in your factory?"

The CEO did not get the analogy.

Finally, one doctor said, "Can you hear yourself? Don't you hear what you are saying?  You are saying you are here today to establish communication, but you do not want to hear anything we are saying. Is there something wrong with this picture?"

She did not understand that comment and she went on to say she thought we needed to set up a committee to improve communication with the doctors. 

One of the other administrators noted doctors do not attend the committee meetings because they are not paid for committee meetings and they insist on seeing patients, for which they get RVU credit toward their pay checks.

Eventually, the patients will feel it. Right now, it's just the doctors.