The Book Club

Recently, the Phantom's wife had to develop a list of books for her new book club. Making lists, creating Excel spread sheets, planning in general--itineraries with clip art for trips and even for weekends in New York City--keep her happy, so the Phantom paid little heed, at first. 

But then, the Phantom began to consider, what literature would the Phantom choose?  The Phantom has never been part of a book club, and in fact, the idea of sitting around listening to other people talk about books he holds dear strikes him as a recipe for disaster. 

But what if the townspeople of Hampton, New Hampshire appeared before his door with torches and pitch forks demanding The Phantom lay out a course for high school seniors, based on the imperative that before these kids leave town, they be equipped with a broader range of experience than Hampton  was able to provide.  What would the Phantom present to these teenagers?  

For fiction, West With the Night, The Bell Jar, Peyton Place, A Farewell to Arms and the Stuart translation of The Stranger, and, of course, "The Wire," all five seasons, start to finish.

Non fiction would include A Stillness at Appomatox (Bruce Catton) , The American Past (Roger Butterfield), A People's History of the United States (Howard Zinn), Battle Cry of Freedom (James McPherson), Omnivores Dilemma (Michael Polan), Moneyball (Michael Lewis) Only Yesterday (Frederick Lewis Allen) and Parachute Infantry (David Webster.) We might throw in "Band of Brothers, " just to be balanced.

These are just the off the top of the head choices--likely The Phantom is forgetting many equally important and worthy choices.

But these experiences, which is what literature really is--an experience--would provide at least some guarantee that eighteen year olds left the protected shire with a sense of the the dangers, the wonders and the adventures out there in the rest of the world. And it would provide American teenagers a sense of where they came from. 

Of course, ultimately, none of us know where we came from or where we are heading. We are just living out our 60 to 80 turns around the Sun with no real idea about the ultimate mysteries. 

Every now and then, The Phantom closes his eyes and tries to remember where he was before his first memory.  Or, more recently, where he went when he was sent off to Never never land by general anesthesia. Where is that black void-y place? And where was The Phantom when he visited that there or that nowhere?

These questions are too large. Better stick to the answers provided by those works listed. That's enough for a start.





 

Morality and Amorality: The Wire vs Game of Thrones

Pawns:  Poot, Bodie, DeAngelo, Wallace

The Most Interesting Man in the Kingdoms

What makes a work of fiction "dark?" 

What makes it tower?

Clearly, darkness can emerge from a willingness to create a character with whom the viewer/reader develops a relationship, a liking, and then destroying that character.  This violates a standard expectation in story telling:  If you have an author who has spent the time and energy to create a really interesting, likable or admirable character, one does not expect that author to kill off that character at a fairly early point in the plot. The reader is likely to simply hurl the book across the room or to change channels. 

 On the other hand, the author who does this is usually careful to have created other characters the reader/viewer still cares about and this is a way of reaching a deeper sense of reality--this is the way the world is. You lose people you love. They die, but you persist. You are saddened, angered by the loss, but you have others, perhaps others you love less well, but others, with whom you must continue to travel on.

Both "Game of Thrones" and "The Wire" television series do this sort of sacrifice. It is very effective in establishing a sense of dread. You have been shown anyone can die at any moment, often when you least expect it. The graveyards are filled with indispensable men and women.

This sort of literature violates the notion of just deserts. There is no such thing as punishment for bad behavior in this sort of literature. The more ruthless you are, the more likely you are to prevail. It is sympathy, adherence to a code, "morality" which is likely to get you into trouble, because it makes you do things which are not in your own self interest.  Sir Douglas sees decency and goodness in a young man and he sets him free after his king has sentenced the young man to death. By the time this happens, you have seen several other characters who have believed in goodness, loyalty and kindness beheaded, throats slit or otherwise dispatched, so you  expect Sir Douglas to suffer for his goodness.

In "Game of Thrones"  the most nimble and cynical character, the Dwarf, tells his sister he does not want to rape the orphan with whom he is obligated to produce a child because "She does not deserve that."  His sister, whose own true love is her twin brother, a brother with whom she has had at least one child, replies, "Oh, you do not want to start down that road, the road of deserving or not deserving."  And we all know what she means--that is the road to destruction.

"Game of Thrones" is filled with people who enunciate strong moral codes--the most vicious and sinister Lancaster believes in family first--he is willing to murder the entire Stark family while they are guests at the Red Wedding and he is willing to order his son to rape and his daughter to marry a man she loathes in the name of family.  
Loyalty to family, perceived insults to family all lead to death and destruction in "Game of Thrones," and pronouncements of desire to avenge unjust killing drives many of the plots. The Lancasters are a sort of early Taliban, full of piety about family and realm, and ruthless in their execution of that sense of righteousness.

The people of "The Wire" waste little time or energy on ideals of right and wrong. Their morality is strictly practical: You do not betray your gang because that would place your people in direct and immediate danger and that would mean you will not last long,  yourself. The only good things in life are material:  bling, drugs, sex.  There is some talk of family by the Barksdales, but that is set aside when practical considerations arise. 

The only person in "The Wire" who talks about a "code" is the one character most outside all human groups, the isolated, unaligned man who lives alone, apart: Omar. Omar has a code.  And it is Omar who is the target of a shooting on Sunday morning, which violates a basic ghetto rule . The rule has been observed for practical reasons.  The players need to go to church because their families demand it, so Sunday morning has been set aside as a time when there shall be no shooting. Stringer Bell violates "Sunday morning" when it becomes impractical and inconvenient. Omar is indignant and vows to make Bell pay for this perfidy, violation of a practical standard of behavior.  

Of course, Omar's most trusted adviser, Butchie, tells him this vengeance  is impractical and Omar, briefly relents, but he is driven to avenge Butchie eventually, when Butchie becomes a target--again, the lone major actor in the entire series who is driven not by money, or drugs or sex or any of the practical worldly pleasures, but by a sense of outrage.

And in the end, Omar meets his fate not because he sought the uphold a sense of justice, but almost randomly.  He happens to turn his back on an eight year old who has a gun and who seeks glory. Ironically, it is an eight year old.  Bunk once appealed to Omar's conscience by describing how eight year olds emulated Omar's role in a street shoot out. Bunk shames Omar by describing eight year olds playing "bang, bang" in the streets after the shooting. "Oh, let me be Omar!"  And Omar is visibly disturbed to have become this new sort of street icon.  "Oh, how far we have fallen," Bunk says and it stings Omar, the one person in the series, white or black, with a conscience. There are only two characters over the series who show any real perspective about the meaning of their own lives: Omar, who is stung to think children want to follow in his footsteps,  and Wee Bay, who looks his wife in the eye and tells her they must set their son free from the drug culture and allow him  to seek a different life.  "You a soldier," his wife protests. "He can be a soldier. He can step up. Your name ring out." 
And Wee Bey, sitting on the other side of glass wall, in prison, shrugs and looks over his shoulder at the guard behind him, at the door back to his cell block and asks, "Yeah, and who would want that?"

What Wee Bey is saying, of course, is the only thing the pride of being a good soldier, a remorseless killer, has really ever led to is life in prison. "What's so great about my life, that I would want this for anyone else?" Wee Bey is saying.


For Omar, the world works as long as he can live alone, launch surprise attacks, take down his prey and then disappear. He lives in a jungle, and his morality is the morality of cheetah. Kill or be killed. He only gets into trouble when he develops a liking for somebody, like Butchie, or when he allows himself to be shamed.

"Conscience do cost," Butchie observes.

"Game of Thrones" is a work of rich imagination, riveting, thought provoking but essentially gratuitous. It's lessons are not rooted in this world. There are dragons, and kingdoms and thrones--all the things which fire the British imagination. From the Arthur legends to the Harry Potter books, when in doubt throw in some magician or a dragon or two. As is true of the most engaging British literature, like "Downton Abbey" there is wonderful dialogue, thrust and counter. It is a sort of glittering intelligence, fun and frothy.

  But in the end, it is "The Wire" which defends no code, which shows only amorality at work in the dystopia of a godless wasteland,  which teaches the most profound lessons. There are no dragons in the streets of Baltimore, no magic, no walking dead. There are only the truly dead, covered with lyme or blood or buried in the parks or tossed in the harbor.  Life in "The Wire" has only the value assigned it by politicians, newspapers, church people and fools.

The Pay Off At 38,000 Feet

Two hours out of Boston the man in the middle seat, across the aisle from me slumped forward in his seat, pallid, sweaty, unconscious.  
The man in the aisle seat jumped up and went for the flight attendant. 
I climbed over my wife in the middle seat and the woman in the aisle seat to get to him. 
He was awake, but not alert when I got to him.
The flight attendants arrived and did the is there a doctor on the plane announcement. 
As far as I could tell, I was the only one to respond. Flight from Boston to a very big doctors' convention and I'm the only doctor.
The patient, a 48 year old cabinet maker from Attleboro denied chest pain, abdominal pain, headache back pain. He denied smoking and any recent alcohol. He had eaten a hamburger in the airport before departure and had not been up late the night before, although he had to fight through a monumental traffic jam to make the flight, which was taking him to a mega bowling tournament in Reno, Nevada by way of San Francisco.  He gave all this history soaked in sweat and pale as a seagull's white head.  His father, a smoker, had died at 68 of an MI, but his brothers and uncles had no known heart history. The patient himself had no heart history, but had no health insurance and had not been seen by a doctor in years. He had been a fitness instructor in the Army, and his plastic goody bag was full of granola bars and he said he never ate fatty foods--the hamburger had been his first in months.

 His pulse was, best as I could tell, about 40 something when I first reached him, but regular, and it seemed to be getting faster as I held his wrist and talked to him. I could not hear his BP with the background engine noise, but it palpated at a systolic of 90.

The first decision was whether or not to move him.
He said he thought he might feel better if he lay down. 
I asked him if he wanted to pee or go to the bathroom and he answer was the first major punch to my solar plexus: He said he might be able to have a bowel movement. Didn't have to have a bowel movement but might be able to.

Forty years ago, a nurse at New York Hospital had called me to the bedside of a man just back from the cardiac care unit who was sweating and nauseated and complaining of chest pain and when he said he needed a bed pan the nurse ran for the crash cart and called the Cardiac Team. He arrested right in front of me before she could return. I asked her how she knew and she said, "When they're having chest pain and ask for a bed pain to poop, they are about to arrest." Everyone else from professor to nursing student nodded in assent.

Now my patient was talking about the same vagal nerve discharge sign.

I walked my patient down the aisle with my arms under his arms. He was 6'2"  215 pounds and outweighed me and I just hoped he would not collapse in the aisle but we got him the 13 rows to a row of seats the flight attendants had cleared off and he was able to lie down.

The flight attendants arrived with a pack which can be used  to defibrillate a patient. I had seen this pack at work but had never used one. They didn't have these things the last time I had to run a code in the hospital 30 years ago. I did know you could use them to get a rhythm strip EKG and to my great relief, he was in normal sinus rhythm at 60. No shock needed, which was a good thing because those airplane seats have metal feet and I wasn't sure about whether shocking him would shock me, the flight attendants or near by passengers. 

A woman who identified herself as an ER nurse arrived and asked if I wanted an IV. I did and she placed one in his right antecubital fossa and lo and behold the emergency kit even had normal saline to hang.  The flight attendants did this using a wooden hanger, hooking this to the overhead luggage rack. Apparently, they had done this before or were well trained or both. 

It bothered me the nurse had used the antecubital fossa, because in the old days, when I last did my IV's the metal butterfly would not last long when the patient bent his arm, but now the IV is a plastic, pliable angiocath and does not dislodge or cut the vein. We had angiocaths back when but removing the metal part was complicated and I preferred the old butterfly. They had prochlorazine in the kit and the nurse asked me i I wanted to give him some for his nausea.  When nurses ask questions like that under those circumstances, they are not really questions. That's what they did in her ER with this kind of patient, but I was reluctant because if he got less nauseated that would tell me he was actually getting better. Give him prochlorperazine and you lose that symptom to follow. On the other hand, if he was nauseated and started vomiting that would stimulate his vagal nerve and slow his heart rate, so I said yes.

The bottle had a rubber top and I put a 21 G needle on a syringe and pulled up 12.5 mg and handed it to the nurse to inject into the port on the IV line but she told me to take off the needle. "How're you going to inject it without a needle?" I asked. "These ports are needless now," she said, all but rolling her eyes. She knew she was dealing with an old gomer doc who hadn't run a code since needleless equipment came in. 

The flight attendant asked what I had given and I said, "Compazine" and the nurse said, no, it was Phenergan.  That's how old and useless I was: couldn't even remember the difference between those drugs, and just knew the brand names. 
(Actually, I looked online and Compazine is prochlorperazine and Phenergan is promethazine, so I was right.)

The nurse said her work here was done and left. 

I asked the flight attendants if I was the only doctor on the plane, a plane from Boston, the medical Mecca. She said they were one or two others but they said I looked like I had the situation well in hand. I said I'd like to have them come forward so we could have a Grand Rounds to discuss what to do with the patient. None ever showed. 

He was looking better, less sweaty and more comfortable and I was able to prod his abdomen which was soft and non tender without rebound.

I kept the monitor on him and the IV running. His rhythm monitor beeped along happily in NSR at 70. He dozed off but was easily arrousable and no longer wanted to poop.

The flight attendant arrived with a serious look and said the captain wanted to know if I wanted to divert the plane for an emergency landing.  She reminded me ominously, we had 4 hours to San Francisco.  

I had been thinking about this:  Over the years I had had young men without cardiac risk factors lose consciousness when I drew their blood. One even became briefly asystolic and I had to revive him with a chest thump, but he recovered and left my office, apparently unharmed. Like these men, this patient had no cardiac risk factors and he appeared to be recovering and was currently stable.

On the other hand, had he known cardiac disease, a midsternal incision from a prior bypass procedure, I'd have landed that plane. 

But I had, over the years, seen patients who initially seemed to be recovering and doing well arrest suddenly and die.

The flight attendants had asked for my medical license number. Everyone was covering the company. I was acting as a Good Samaritan, but if I sat there for 4 hours my Good Samaritan status might just expire and I knew I was exposing myself and my family to a possible career ending lawsuit.

On the other hand, this man had no health insurance and a visit to the hospital could do him significant financial harm. And what hospital? We were approaching Utah, and there is one of the best hospitals in Salt Lake, the University of Utah.

On the other hand, he was looking better and better, just the way my other patients who had vaso vagal episodes had when they recovered. 

I told the flight attendant they should have the EMT's meet us in San Francisco but I thought I could monitor the patient for now. She looked at me hard. I said I knew there was a contradiction there. If I needed EMTs at the end of the flight why did I not need them now? But what I was saying is I didn't want him getting on a flight to Reno without more evaluation, but right now, he looked okay. I'd leave that IV in for safety. They had epineprhine, atropine, and Heaven Help us, intubation equipment in the airplane kit. 

My wife moved up because the 70 somethings in the seats on my side of the aisle asked if he could have anything infectious and they wanted out. My wife arrived and said brightly, "Wow, much more leg room in these forward seats. You upgraded us."

She's a former ICU nurse and I told her to watch the monitor while I went to the bathroom.  I needed it but I also wanted to scout out the bathroom because I figured he might need to use it to urinate after his next bag of saline.

When I said, "I can't believe I'm the only doctor on a flight from Boston. Next to Washington, DC, Boston has more doctors per square inch than anywhere."

"Can you imagine your young colleagues coming forward?" she asked.

It was true. My young colleagues did not want an EKG machine in our office because they did not want the responsibility to read them or to act on them. This means 70 year old diabetics can come and leave our office with atrial fibrillation without anyone knowing. I examine every heart every time. "But that's not what we are here for," they told me. "We biopsy thyroids, get blood sugars down. We are not internists. We are endocrinologists, specialists."

But these are people, patients.

The head flight attendant came by to tell me she was applying for a refund of my ticket price because I was doing a service for the airline.

That was my Hemingway moment.  Hemingway, in The Sun Also rises, talks about the difference between living in France and living in Spain. In France, you tip your waiter well and the next time he gets you a good table and may even smile at you. It's all based on money, cash exchange. In Spain, the hotel keeper will not even give you a room during the running of the bulls time unless he knows you love bullfighting, unless he knows you share the passion for the sport. It's all about honor and passion and stuff like that. Money just sullies the whole relationship.

So now, I know it came from a generous and grateful place, I was being told I had performed a service for the airline and I was being paid off, and I should be gracious and say thanks for the money.

But it sort of made me sad. The patient was not even out of danger and they were already talking about the fee for my service.

After his 2nd liter of normal saline, he sat up and said he felt much better and his color returned to the shade of the living and I sat next to him and kept refilling his water cup and we talked about bowling, his time in the Army, his business as a cabinet maker and restorer of old New England homes.

We both noted, after a liter of intravenous saline and a liter of bottled water, he still did not need to pee, so he must have been dehydrated.

I was very glad he did not suddenly keel over and die.

He was very well by the time we landed in San Francisco and the EMTs arrived and asked for the doctor and looking at him they gave me the fish eye for the false alarm.

My wife told me not to worry about it. After all, nobody else had thought it was worth the money.





 




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Misdiagnosis: The Red Wedding for American Physicians

When Americans complain about one failing or another of the American healthcare system today, they typically find the demons where they want to find them: For those who hate Obama for, well for being Obama, every annoyance, every absurdity has one root cause: Obamacare. For those who resent rich doctors, it all comes down to arrogant, greedy doctors.  For others, it's the pharmaceutical companies. Pick you own devil.

Over the past decade the rich, greedy doctor story has regressed as people see doctors regressing into the middle class. As in many other things about the American health care system, American medicine has been drawn by the strong, ineluctable gravitational pull toward the state of where the British medical system was 40 years ago.  The median salary for pediatricians, primary care doctors, depending on the part of the country is between $80 and 100 thousand  a year, about what the owner of a couple of McDonald's franchises could make.  While there are still some specialties producing millionaires, the doctor's house is no longer the biggest in town, if it ever was.

There are many reasons for this regression toward the mean in doctors' economic lives, some of which are rooted in efficiencies.  The parts of a doctor's work have been analyzed, picked apart and the systems which form the patchwork quilt of our largely unplanned American system have been divided--so now most of the sore throats, rashes, headaches, nausea are seen by nurses, nurse practitioners, or the new category "physician assistants," people who did not have to be at the top of their high school and college classes, people who invested only two to three years of post college training before starting practice.  There is some efficiency and wisdom in this trend, but it is not an undiluted virtue.

Recently, the Phantom witnessed another part of this story, as he watched the disintegration of the best internal medicine practice in his small New England town.

This was a practice in which everything was done right. Before any patient was referred to a consultant a thorough, highly competent and efficient evaluation was done and once the decision to refer was made, a letter of introduction to the consultant was sent, so the consultant knew exactly what the question was. Phone calls to consultants, nursing homes, patients and their families kept lines of communication humming and vibrant.These doctors did far more than triage and turfing, i.e. hearing the complaint and sending the patient off to a dozen consultants. These doctors did what medical school and years of experience taught them to do--they did real medical care.

The group, which included six physicians, four full time male physicians and two part time female physicians saw their own patients, many of whom they had followed for twenty years or more, in their office from 7:30 AM until 4:30 PM, and then they walked across to the street to see their patients in the hospital.

Even when the hospital hired "hospitalists" to take care of hospitalized patients, these doctors saw their own patients in hospital.  "Being in the hospital is often the worst place a person can imagine finding himself," one of these doctors said. "When they are sick and frightened, they want to see their own doctor."  

As hospital stays got cut shorter and shorter, the number of patients this group had in the hospital dropped precipitately--rounds were no longer on 12 patients but on 2, and those were likely to be on Medicare patients, for which the doctor got $35 to $48 dollars a visit. Oddly, the time spent in the hospital did not drop commensurately. Chasing down lab results, nurses, consultants, radiology reports, X rays, talking with the patients' families still kept these doctors in the hospital for hours, for that $48.

Eventually, it came down to a choice: "I could spend from 4:30 to 6:30 PM in the hospital seeing two patients for $96 or I could see 6 more patients in my office, usually bringing in about $480."  The office, in terms of economic reward was obviously the place to stay. But these doctors did not want to "abandon" their hospitalized patients. The kept walking across the street.

Ultimately, the dollars and cents brought them to a decision. With rising office rent, staff salaries and health care benefit costs, with falling insurance company reimbursements and more staff needed to deal with the different insurance companies, it got more and more difficult to meet payroll.  

The practice, after much agonizing, sold out to a big hospital and medical system chain and they became employees. They promised, under a "non compete" clause, not to practice within 20 miles of their office if they decided to leave the employ of the company.  So, if they parted ways with the company, the company "owned" the patients these doctors had cared for for 25 years. They had crossed a Rubicon. Once hired, they could never resume their own private practice again.

At first, they were happy; they could stop worrying about money, got  their monthly paychecks and just saw their patients.

But when time came to renew their contracts, they were told the company which employed them was shifting to a new "model" in which the financial risk of the practice was shifted to the doctors. The overhead of the practice, the rent, staff salaries, photocopying, billing, supplies would have to be met by practice collections before the doctors could be paid from what remained.  The company had not been particularly competent in negotiating deals with insurance companies, so the income actually collected by the practice had fallen, despite increased billing totals. 

"It was the worst of both worlds,"  one of the docs said. "You could no longer control the costs of practice, and you could do nothing to increase the income."

In fact, the company added another physician to the practice when it was not clear there were enough new patients to justify it. "We need to increase market share," the doctors were told. 

The doctors were particularly appalled to read the company, nation wide, had been hugely profitable as they were cutting the salaries of the doctors. A new head physician had been hired in the company's central office in a distant state, at a salary of $15 million a year.  The doctors tried to contact him but he replied he only talked to "market leaders"  and that he was considering "reformulating my communication strategy" but that once he had figured out how to "leverage our scale across similar services" he would, possibly, get back to them. He was very busy figuring out how to achieve dominance of practice and market identities, so he could not project from home base to the local practices just yet.

"I had no idea what language he was speaking," said one of the doctors.  "I think it must have been MBA speak."

One doctor simply quit. Two of the doctors found new practices in North Carolina.  "I've got, I hope, 20 more years to practice," said one. "I just cannot deal with these people."  This doctor had been an anesthesiologist for about ten years, earning among the highest salaries, working regular hours, bored stiff. He re trained for internal medicine, did office hours, rounds and saved lives, and loved it. But the company defeated him. 

He found a new practice and he moved his family from New England to North Carolina. 

"It's a wrenching experience," he said, as he packed up. "But what else could I do?"

His is a choice many more of his kind will have to face.  He is like one of the Stark family in Game of Thrones.  He chose honor and a code and that's what did him in: He was invited to the Red Wedding.

Patent Trolls, Intellectual Ventures, NPR and Leeches in the American Judicial System

One of the first things the United States government did when America became a country was to establish a patent office. The founding fathers realized you could not run a capitalist economy if you did not have a functioning system of patents to protect innovators and to make innovation worthwhile and profitable.

But, as Laura Sydell and Alex Blumberg have detailed in a wonderful piece of long term, long form reporting, patent law has become so corrupt and dysfunctional, it is now a threat to the national security, the national economy and national sanity.

If we can believe Ms. Sydell and Mr. Blumberg, and listening to this report the Phantom found it hard not to believe them, the case is clear. These two reporters pursued a "company" called "Intellectual Ventures" and its co conspirator, Chris Crawford, and they unraveled a scheme which these predators devised to extort, and in some cases ruin, businesses, profiting fantastically and more or less legally, in the millions of dollars.

The report runs 15 minutes on the radio, but it can be boiled down:  1. Chris Crawford obtains a patent from the U.S. patent office fraudulently, by claiming he developed a technology which allows consumers to order things over the internet. (In fact, he did not develop this, but stole the idea, which was not actually new enough to warrant a patent.) 2. He then colludes with a "company" called Intellectual Ventures (IV)  by "selling" his patent to IV  for $12 million dollars and then appears as the star witness at the trials of companies IV sues for violating this fraudulent patent. Of the 20 companies IV sues, 17 do not have the money to fight the case in court, so they settle for a grand total of about $100 million. But three of the companies fight the suit in court and, in the process, they expose the fraud in Mr. Crawford's application for the patent in the first place. The jury, and the listening audience, can readily appreciate the fraudulent nature of Mr. Crawford's claims and IV loses the trial. 

But it really doesn't matter to IV it lost the trial, because it has already profited by threatening suit in the other 17 cases and simply raking in the settlement money.

Although Mr. Crawford has obtained what is clearly a fraudulent patent, neither he nor IV are ever prosecuted.  They can keep their money, free and clear, despite the harm they did, and the lies they told. 

There are, of course, more guilty parties here than Mr. Crawford and IV. The patent office, of course, was guilty of issuing a patent which never should have been issued. The patent office simply performed in an incompetent manner, and 17 companies suffered mightily because the patent office failed to do its most basic function. 

The legal system, which did not rescind the millions in settlements wrongfully claimed by IV failed to police its own ineptitude and allowed the courts and the process of out of court settlement to injure innocent companies, their workers and their workers' families.

Companies who settled had to lay off workers, some failed in the wake of the damages and some are still paying off the settlement.

Of course, anyone listening to this sad tale asks: Why have Mr. Crawford and IV not been brought to justice? 

The Phantom can only imagine:  1. Going after the extortionists would be hard work and the government prosecutors have no appetite for that.  2. Patent law is inherently corrupted by the problem of ignorant juries who simply cannot follow the technicalities of the cases.  3. The entirety of our judicial system is based on this basic corruption:  No matter how bogus your claim, no matter how ridiculous your case, if you have enough money, you can bleed your opponent dry if he does not have enough money to fight the case through the courts.

This basic principle applies not just to patent law cases, although these cases are often among the most egregious examples of extortionate  use of the American judicial system--innocent victims of predatory lawsuits from doctors faced with bogus malpractice claims, to business owners to newspapers are often simply unable to fight the extortion because it would be financially ruinous to try.

This whole notion of allowing the rich to dominate the relatively poorer through legal phlebotomy has been so ingrained and so brazenly practiced nobody in this country stops to think--why do we tolerate it? 

We cannot shrug off  patent trolls as disgusting, but non life threatening leeches on the basis of believing rich people do not harm the basic fabric of American life by their attachments and exsanguinations. It must be because legal rape has been so deeply entrenched for so long,  we fail to see the evil any more. 

In Britain, the party which files a patently absurd lawsuit is often assessed court costs and penalties to make whole the innocent victim who has been attacked. 

For reasons which escape The Phantom, that is not done in these United States.

False accusation, felonious legal assault simply goes unpunished here. 

And we all suffer the consequences, one way or another. 

Colonoscopies: Raping the System?

This post may well be mis titled. 

The designation of "rape" incorporates an unwillingness on the part of someone. Any interaction which involves a willing buyer and a willing seller should not be designated a rape. But, in the case of medical services, there is this peculiar situation where the person most at stake is thrown out of the loop of negotiation. The service seller, the doctor, his facility and his business negotiates with an insurer for a service consumed by the patient, who is not consulted about the cost and payment.

In today's New York Times, front page, above the fold, is an important story about the factors which drive up American medical costs to astronomical levels seen nowhere else in the world. The example examined most closely is that of colonoscopy, but other examples are cited, including MRI exams, angiograms and hip replacements.

The Phantom has wondered for years when someone would blow the whistle on colonoscopies. This is a procedure which can be learned in a few months and mastered a year or two, which requires no special knowledge of anatomy or physiology beyond what could be taught over a short course to people with high school level educations. It's cost in most Western nations with national health systems or even with private systems falls somewhere between $450 and $750.  Across the United States the cost varies ranging from $665 in Utah to $8,577 in New York. 

The procedure, used to screen healthy people for colon cancer, has been around since the early 1970's and has provided a cash cow for gastroenterologists ever since.  These doctors, trained to diagnose and treat diseases of the intestines, stomach, gall bladder, liver and esophagus have given up the practice of medicine to focus on what returns the most dollars, namely a day filled with colonoscopies. 

The incentive factor was most famously illustrated by the NPR piece on a medical student who was at the top of his class at Mt. Sinai Medical School in New York City, who was called into the Dean's office because he had chosen to do his residency training at a community hospital in Florida rather than at a Harvard university hospital , where his grades and test scores would have assured him a place. 

"Look," the medical student said. "If I got to Harvard, I'll have to publish and I'll have to work on papers for the professors and it will be long hours and plenty of sweat. All I want to do is colonoscopies from 9 AM to 3 PM and be on my boat with my wife and kids by 4 PM. That I can learn to do in Florida."

So much for medicine as a calling. 

The procedure which would place this medical student on Easy Street has done the same for thousands of gastroenterologists before him over the decades. And, as the Phantom noted, it is remarkably simple to learn, and safe and easy to do.

The Phantom had a friend from internship who learned the procedure in a few months, got out into practice as quickly as he could, and borrowed money to buy his own office and his own colonoscope ($3600) and he did colonoscopies in his office and bought a beautiful Manhattan Coop within two years, and a home in the Hamptons, all based on this one procedure.

And he was a bargain, by today's standards, because he did the procedure in his office, and still does. As a result, his patients do no have to pay for an anesthesiologist, or a "facility fee" the way they would have to if he did not own his own instrument but instead did the colonoscopy at a "facility," either one owned by his practice or by a hospital.  Over time, everyone figured out how to get into the act:  the facility people got their cut; the anesthesiologist got his cut. And prices just kept climbing.

Of course, at any time, the insurance companies could have put an end to this legal exploitation by simply saying, "No."  Medicare eventually reduced the payment to $140, about what it is worth. But most colonoscopies are not done on Medicare patients.

Originally, the GI docs argued colonoscopy required 4 years of medical school, a year of internship, three years of GI fellowship, and they argued the procedure required high skill to avoid colonic perforation, and it required a doctor to administer intravenous "conscious sedation," usually Versed, so they somehow convinced insurance companies to fork over more for this procedure than Medicare was paying cardiac surgeons for doing coronary bypass procedures, where one mis-thrown suture literally would cost a patient his life.

Heaven only knows why the insurance companies were so pliable. Maybe they feared losing customers over this.

MRI's are another profit center. In Europe, patients have an MRI exam of a knee for $70; in the USA that exam runs $2500.  In Europe, the doctors who own the MRI machine, if doctors own the machine at all, will have to pay that machine off over 4-5 years. In the USA a $3 million machine runs 24 hours, 7 days a week, except for servicing and is paid off with 1,200 MRI studies, in about 12 months. 

Billing for medical services has become so Byzantine in these United States, there is little hope of unraveling this Gordian knot, to mix a metaphor. The only real way is to cut through it with a sharp sword, a la Alexander.  That sword would be a single payer, Medicare for All, as far as The Phantom can imagine.

Everything else, including Obamacare, where the insurance companies still do what they do, is just nibbling around the edges and doomed to fail.

 

 

Drunken Sex and Male Culpability

Annie Kendzior

Back in the unenlightened 50's and 60's women were supposed to be virginal at marriage, but as the 60's turned into the 70's that got amended to women were supposed to be virginal until they got drunk at college and "didn't know what I was doing" and had sex. But that didn't count, because, that really wasn't me who had sex, just the drunken alter ego me. By the 80's women could have sex before marriage if they were in a "committed" relationship, which is to say, it is okay if "Well, I was in love with the guy."  By the 1990's Gore Vidal and Tom Wolfe were reporting college girls had given up all pretense of not wanting sex except in certain, restricted circumstances, but were inclined to "hook up" with boys every weekend, for fun and pleasure.

As far as Mad Dog can tell, this summary of evolution of sexual mores among college girls/women varies with the college.  

During the 1990's a male student at Brown University, a junior, just a year from graduation was expelled because he had sex with a drunken co-ed. He had come back to his fraternity house room and found a naked, drunken coed in his bed, considered this a gift from God and had sex with her. She awoke the next morning, exchanged names and telephone numbers with him and went home to her dorm and had a change of heart. She decided she had been raped. Because all incoming freshman sign a pledge as one of those one thousand pieces of paper you sign during freshman week, the university had the boy/man in clear violation of this university policy, that boys not take advantage of drunk girls.

Now, in the second decade of the 21st century a case at the Naval Academy has hit the headlines. Of course, there can be no adequate analysis of the ethics of a case without establishing the "facts" and the facts may be remembered and perceived differently by all involved. But, at least as it is reported in the New York Times, the sophomore midshipman now says, in her lawsuit, she went to an off campus party and arrived drunk or at least semi inebriated. While partying with members of the Naval Academy football team, she drank more, so much in fact she "blacked out." She says now she can recall only brief moments of that night but was driven home by one of the football players. Later that week, she texted the player who had driven her home and met with him and he told her he and another player had had sex with her. 

Then the consequences began to unfold, in terms of looks she got from the football players, isolation and ostracism by other midshipmen and a general sense of wearing the scarlet "A"--the sort of stuff Mad Dog remembers from when he was a teenager when word got out that a girl was "easy." Now, in 2013, of course, every girl is presumed to be or ought to be "easy"--but not at the Naval Academy, apparently.

Of course, the military has become the last bastion of irrationality and ridiculousness when it comes to rules about sex, as General Petraeus would be the first to conclude. You cannot have sex with a soldier you outrank, which means, exactly, what?  Sergeants cannot have sex with anyone except other sergeants?  If you are married, you cannot have sex with anyone but your own wife. And that is a standard which General Eisenhower would have loved enforcing. While in theater, in combat assignments, we will assign you a young woman to sit in your foxhole with you, and you may not have sex with her.  Just read Kayla Williams (I Love My Rifle More Than You) on that one. As Ms. Williams notes, women assigned to overseas combat postings suddenly find they are, for the first time in their lives, consideredd to be among the most sexually attractive women on earth. On the plane ride back to the United States, the joke goes, "Welcome back to America. All you ladies have just gone from being a '10' to a '4, again.'"

So here is the question:  If a young woman gets drunk, not alone in her room, but gets drunk and goes to a bar or to a party, where a reasonable person might expect she would met young men who are present in hopes of having sexual intercourse with some willing female, does she then  have any right to demand punishment for the young men who "took advantage of her?"

Suppose the woman had not been drunk at all, but merely became excited after dancing with the young man, and went off to his room and had sex and then later decided the music had stripped her of her defenses?

Or suppose the woman  merely said she was drunk when in fact, she had had nothing to drink, but she went off to a room and had sex with a young man who thought (mistakenly) he was taking advantage of her lowered resistance: Would he then be guilty of having violated his oath to not have sex when he had reason to believe the lady's judgment was impaired?

The most cogent question is, of course, if a woman willingly puts herself into a state of impaired judgment, is it required of a young man to accurately diagnose that state and to refrain from having sex with her.

You can see the scene:  
                             Woman: "Take me to your room."
                             Man:       "I'd love to, but are you drunk?"
                             Woman:  "Well, maybe a little."
                             Man:        "Then I cannot."
                             Woman:   "Well, then, no. I'm fine. I just want to have sex. Do I have to be drunk to want to have sex?"
                             Man:         "I don't know? Do you?"
                             Woman:    "With you, maybe. Most guys don't require me to pass some roadside test. Do you want me to walk heel to toe? Touch my nose with my finger? What are you,  a cop?"
                              Man:         "Hey, I'd love to, but I've signed this paper that says I cannot have sex with women who've been drinking too much."
                              Woman:    "Well, how much is too much?"
                              Man:         "I don't know. Maybe we should have you breathe in to a breathalyzer."
                              Woman:    "Or how about we go by the ER and have them draw a blood alcohol level on me."
                              Man:         "That works for me."
                              Woman:    "Get lost, loser."