Leader of the Free World and All that

Cowards Cut and Run: Real Leaders Never Do. That is what you said, Isn't it?

What is it that happens to a man when he gets ensconced in the Oval Office and the White House?

The Phantom is trying to imagine sitting on that couch in front of the desk, with the oval rug with all the stars and eagles on it, and receiving the parade of trusted advisors who present you with problems:  The Syrian Army just gassed its own people. They had been unable to dislodge the rebels from the neighborhoods in the Damascus suburbs, having pounded the buildings into rubble with arterily and tanks and so they finally just fired Sarin gas containing shells. And it worked for them.

But now, as the Leader of the Free World, you have to act. You said using gas was a "bright line" not to cross and they crossed it. They disobeyed TLOTFW! If you expect to be obeyed in the future you have to spank them now! You are the great white (well, maybe not white) father in the White House and you must be obeyed.

If you do not stop this tin pot dictator in Damascus from using gas, then what despot anywhere will fear you in the future?  

Every two bit dictator with Sarin gas will be using it like tear gas from now one, unless you act.

Or something along those lines.

You hear that from John Kerry. You hear that from John McCain. You hear that from who knows who.  But do you ever hear from the Phantom or the guy in Brooklyn who drives the cab or from the mother in Exeter who runs the PTA?

What can guide you?  

History maybe. But whose history?

The last time a dictator systematically gassed people within his borders, or within the territory under his control, it was Adolph Hitler and he could not be stopped from doing it until several armies from the largest powers on earth fought him to the death for 7  years. 

What makes you think some cheap shot across the bow, some finger wagging from 1600 Pennsylvania Avenue will scare some desperate despot who is already fighting for his life and has the morals of a cornered rat?

Now, if the Phantom can just get Mr. Obama on the phone.

Mr. Obama's problem is he cannot even read the Phantom's blog. His handlers took away his computer access and his smart phone.  If Mr. Obama could read blogs, he could tune into Mad Dog Democrat, or any of a variety of thoughtful, informative voices from the heartland, and he would know nobody expects him to be, nobody who counts wants him to be the master of the universe.

That job has already been filled. We got one. And he doesn't live at 1600 Pennsylvania Avenue.

Don't take that jacket too seriously.

The Safe Path in Life

Alexandre Yersin

Our parents want what is good for us. That is a different thing from what is best for us. 

The best jobs now available in America did not exist when The Phantom went to college. The new best jobs involve computers, sometimes programming, but mostly they require seeing the world differently, through new eyes.

What school systems from grade school through college provided, at least in the Phantom's generation, was discipline. They provided content, "facts" a "knowledge base" so the students could learn what had come before, so as not to have to reinvent wheels, but the pathway forward would require students rejecting what their parents and teachers taught.  

Professor Andrew Hacker asserts the pathway to Princeton did not prevent students at that jackpot school from regressing to the mean, from doing no better or even worse than their parents. The pattern, he implies, is a set of parents who had to make their own way, who had to struggle, who then provided an easier way for their less intensely competitive children, who did not have the fire in the belly and who regressed to the mean. 

That does not comport with individual stories the Phantom knows. Driven, "gunners" fought their way into Princeton, but like all eager to please young people, they had difficulty rejecting the hands which fed, so they followed conventional paths, to law school, med school, traditional business, and none of those destinations offer as robust a return any more.  Even those gunners who attained Goldman Saks discovered they were caught in a pyramid, making lots of money at first, but then winnowed out after a few years in that hyper competitive  cauldron.

As Dylan said, "Your old road is rapidly aging. Please get out of the new one, if you can't lend your hand." The old roads are no longer the best paths.

The wisdom in these words was never fully apparent to the Phantom, but it is becoming  clearer, with time.

What the parents wants for his child is a recognizable path toward a secure future. Go to law school, get a job, we won't have to worry about you. 

Except of course, law school no longer means a job.

And medical school means only a very middle class job now, in America, except for the top 25% of medical school graduates. Medical school graduates are now following in the footsteps of law school graduates--they are bailing out of the profession for which they've been trained and going into more promising careers.  

Looking at the mid life status of his sons' friends, the Phantom is stunned to see the kids he thought had fallen off the cruise ship to stardom were the ones who actually became the stars, while those who remained on board are mired in "careers" which provide a steady paycheck, but it is not clear for how long.

It is instructive to look at life stories, such as you can apprehend them. Alexandre Yersin, trained by Pasteur at the pre eminent institution in Paris, leaves the security of a career at the palace, sails for French Indochina, winds up identifying the causative organism of the disease which laid waste to Europe for centuries--the plague. And, just to add to the excitement, he raises an anti serum to this disease, launching the first successful treatment, before antibiotics.

For every great success, there may be a thousand failures, who also took their own path but it led to failure.

The question the Phantom would like to see answered: What happens to the failures? Do they wind up homeless, or do they find another path, find at least some success?

Who has these answers?

Behind the Mask: The Phantom

The Phantom has been prevailed upon to provide some background on the name of his blog.

As a rule, The Phantom prefers to live out of sight, to reveal as little as possible about himself, to live in his skull cave with his wolf, his horse and assorted family members who may drift in and out from time to time.  As readers of the comic strip will know, the Phantom line began in 1570 something when pirates killed the Phantom's ancestor and the original Phantom swore on the skull of his father's murderer to avenge such piracy, to fight for the right and to punish wrong. Succeeding generations kept up the fight for right and justice and the comic strip.

One of the wonderful things about this strip is that, while there were always adventures afoot, things changed only glacially, so when the Phantom's brother went off to college, where he had no access to a daily newspaper, he could come home on vacation and pick up the story line without problem--having missed the intervening 3 months. The only other comic strip with this sort of  glacial quality was Prince Valiant, but there was no way the Phantom or his brother or any member of his family could ever wear his hair like that.

When the Phantom himself went off to college, he was placed, freshman year,  in a room off a stairwell. This particular dorm was populated mostly with upper classmen and a variety of jocks, from a variety of teams. The Phantom himself was actually a recruited athlete but the college happened to be part of the Ivy League, so no scholarship was involved and once admitted, you had no commitment to actually show up in the coach's office. The Phantom did, however feel honor bound to post at the coach's office,  but when he was handed the travel schedule for the team, he realized he would have to miss chemistry laboratories which were held late Thursday afternoon and the team was frequently traveling then. Since the Phantom was pre-med, this presented a problem. 

The Phantom was 18 years old and decided he could either enter into a lathered pursuit of the variety of female pulchritude on campus, do his sport and join a fraternity or he could go to class and when he was not in class he could live at the library or in the laboratories and he could time his visits to the Ratty (the campus cafeteria) in such a way he could eat his meals alone,  and in under 5 minutes.

The Phantom lived by a schedule he drew up every morning and popped into his front shirt pocket,  and he did not dwaddle. He did not go to the Ivy room for coffee after class. He did not go on dates. He went to the library whenever he was not in class, where he camped out in the stacks at a study carrell, which he claimed at 8 AM each morning and to which he returned between classes. He left only for his 5 minute forays to  the Ratty and he did not return to his dorm until 10 PM, where he threw down his books, showered, and went to bed. Any stray dorm rats who happened to be visiting his roommate left the room. Very few fellows--the dorms were all male in those days--ever actually saw the Phantom. Some claimed he did not actually exist and he was the creation of the Phantom's roommate, who wanted a room to himself and simply claimed to have this imaginary roommate. 

At the other end of the third floor hallway, in a stairwell room, lived the son of a prominent Providence, Rhode Island physician named Jim. Jim had a receding hairline and a personality disorder. He did things like rolling bowling balls from the top of the third floor stairwell down the stairs to the landing on the first floor, which sounded, from inside the stairwell rooms, like bombs were going off. Alternatively, when he tired of noisy disruptions, he simply urinated down the stairs after filling his bladder with as much beer as he could gulp down, hoping to someday reach the first floor landing from the third floor landing, but his stream never got much past the second floor, although you could definitely smell the urine as soon as you opened the ground floor door into the dorm. 

Jim did not lay eyes upon the Phantom until halfway through Spring term, when he decided to try rolling his bowling balls down the stairwell at the Phantom's end of the hall.  

Oh, he was told, that would not be a good idea. That guy who lives with the wrestler in that stairwell room lives in there. "Who is this guy?" Jim asked. And then Jim was told of the Phantom's strange, inaccessible, life. 

"He never comes out of the library except to sleep here?" Jim asked.
"And to go to the Ratty for 5 minutes each meal. And to go to class."
"He never goes to parties?"
"Never."
"He can't study Saturday nights. The library closes at 11 Saturday nights, so where's he go?"
"His roommate says he comes home, does his laundry, and writes letters and goes to bed."
"Nothing settles down in this quadrangle until after 2 AM. How's he going to go to bed in the middle of a tornado? This sounds like bull---."
"Well, if you don't believe it, just wait for him Saturday. Library closes at 11 PM. It's a fifteen minute walk. He lives by a schedule card he keeps in his pocket. He should be at his door say, 11:15."
At 11:15 PM Saturday nights Jim was usually at the top of his stairwell urinating, or he was down in the party room swilling beer.  Sometimes he was puking on the stone porch in front of the dorm. But that Saturday night he sat on the stairs at 11:15 PM and he could hear the door open at the bottom of the stairwell.  Jim had finished off a six pack and he was sitting on the stair, at the top of the landing and he could hear the Phantom bounding up the stairs. 
The Phantom saw Jim sitting there and looked him right in the eye, neither hostile nor friendly, neither interested nor uninterested. And he put his key in the lock, shifting his books to his left hand as he did it, all the while never taking his eyes from Jim's rheumy eyes.  The Phantom unlocked his door and pushed it open and looked over his shoulder at Jim before stepping  into his room.
"You're like some friggin Phantom,"  Jim said.

The Phantom turned around to face Jim. A half smile played around the Phantom's lips but his eyes were as expressionless as a shark's.

Jim took one step back, toward the hall door.

"You're that guy who pisses down the other stairwell," the Phantom said.  "Your father's rich and you're drinking your way through school. And you got the place twenty other guys wanted so you could spend your time pissing down stairwells. Congratulations."

Jim was not a small person: Six two, two twenty maybe. The Phantom was less than six feet and no more than one sixty, but he stood about ten inches from Jim and looked right into his face with a look which hungered for Jim's vital organs. Jim turned and fled through the door to the hallway.

Back down in the party room, the music was going and everyone was waiting to see if Jim had sighted the white whale.

"He's like a Phantom," Jim said. "I think I saw his back as he went in the door."

So that's how the Phantom got his name. The Phantom, having always liked the comic strip accepted the name--although he never  acquired a skull ring, or a horse or even a wolf--and eventually, the Phantom grew to like the name.

During the first three years in college, the Phantom spoke to nobody but his room mate, or  he spoke in class but otherwise, he spoke to very few people. There were few people he actually had to speak to. He could go through the cafeteria line withou saying a word. He could enter and leave the library without even eye contact with another person. He knew fewer than a dozen people, mostly other pre meds.  

His senior year, after his medical school applications were all in, he got a girl friend and he started talking to more people.

For the first three years, he spoke to the bare minimum.

 But now, the Phantom speaks.  

Ironically, now that the Phantom speaks, nobody replies. The Phantom has two blogs. When people respond to anything on the Phantom's blog, they do so on the other blog. Maybe it's that security thing where you have to type in letters to prove your not a spam. For whatever reason, nobody speaks back to the Phantom.
 

American Can Do Spirit

So here's how low we have fallen:  The Phantom gets a sad phone call from a patient who says the office of the doctor for whom the Phantom was covering faxed a prescription into a 24 hour CVS, but whoever filled out the RX forgot to write in the diagnosis code (250.02) which Medicare requires, so the pharmacist refused to fill the prescription.  The pharmacist did offer to sell the patient the insulin for $160, which is about a week's pay for this particular patient. But even though the patient had all his Medicare papers and card in a row, the pharmacist refused to run it through Medicare because the doctor's office forgot to write the diagnostic code for diabetes--the only disease insulin is used to treat.

The patient is completely out of insulin and of course it's Friday night at 9 PM. 

Our usual rule is if you are dumb enough to run out of insulin on a weekend, then you have to pay cash for your insulin. Your lack of planning is not our emergency. That is your punishment for failing to plan ahead.  Patient has to pay out of pocket once and he never lets that insulin Rx lapse again. As the doctor, if  you don't get tough about insulin, your life becomes unmanagable, because you get an unending torrent of phone calls  from patients every Friday night, Saturday and Sunday. You get people who plan to fill their prescriptions over the weekend, because it's easier calling the on call doctor than it is to deal with the office staff during the week. You have to train your diabetics to behave,  when it comes to insulin.

But, in  this case, the patient had done the right thing; it was someone in the doctor's office who fouled up, and now it was the pharmacist who refused to simply write the DX=250.02 on the prescription even when the doctor told him to, because the "Medicare rule" is the doctor has to write this on the prescription. (Of course, every pharmacy seems to know something different about Medicare rules.) The pharmacist said he could not take a phone order. The doctor had to write it himself and fax the RX into the pharmacy. If the doctor did not have a home fax, well then drive to the office. But, of course the office building is locked, so go find an all night Kinkos. The pharmacist was willing to deny the patient his insulin to follow the letter of the law.

Now, you could argue, the pharmacy is simply enforcing on the doctor the same discipline the doctor enforces on his patient: Fill out that Rx properly or you wind up inconvenienced and bothered.  But, the doctor may not do that, may not be able to do that, may simply send the patient to the ER (for which Medicare would get an $800 bill, at minimum)  or the patient may give up, go without insulin and wind up in the hospital for a few days at a cost of thousands to the system, all because of insistence on inconsequential details.
 
And we wonder why Medicare costs are high. 

The story gets even better: The patient arrives at the pharmacy and the insulin pen is ready but there was no prescription for the needles. You need to fix a needle to the pen to be able to inject the insulin. Oh, you wanted tires with your car? Actually, the prescription said, "Novolog pen + needles." But the pharmacist wouldn't fill it because "Medicare rules" say the needles have to be a separate prescription.  More calls, more faxes. 

But the best part is, it turns our Medicare does not have a contract with Novo, which makes the Novopen, only with Lilly which makes the Humalog pen. There is not a gnat's eyelash difference between the two, but a new prescription has to be written, faxed.

A typical endocrine office faxes a hundred insulin prescriptions a day. What are the chances some box will not be filled in?  If only 10% are missing a birth date or a DX code, or misspells the patient's name,  that's 10 phone calls every night, often to a covering physician who doesn't know the patient, his birth date or the spelling of the name.

In most systems, you say, okay, let's be tough on the rules which really matter to the functioning of the system, to the safety, clarity or integrity of the system, but for things which are really just book keeping, which could be tidied up in the day light hours, you punt. That's called efficiency and rationaltiy.

Efficiency and rationality do not characterize the world in which today's doctor functions. 

Large parts of the medical system are no longer "professional." The clerk who knows only whether or not the box is checked has no clue why the box needs to be checked, who does not care why its important the prescription is filled or what the ultimate goal of the system is; he is not a "professional." He is a functionary. He works in his part of the assembly line, on the fender bolts. He doesn't care whether or not the care has an engine, whether or not it can run. He just puts in his three bolts, draws his paycheck and goes home.  It's the job of the designers and engineers, the "professionals," to set up the assembly line so a working car emerges on the other end. It's not up to the assembly line worker to think about whether or not that bolt has to be sunk in place.

But, of course, the pharmacists wear white coats and call themselves "professionals." They have schools and accrediting exams, but they do not behave in any way more "professionally" than the guy on the line placing bolts in the fenders.  This is because the pharmacy is a for profit business. Almost whenever you get the profit motive mixed into medical care, you have poisoned the well.

This is not limited to pharmacists working for big corporations, in fear for their jobs. Of course, the pharmacist is not judged for his judgment; the pharmacist's job is not care for the patient; the pharmacist's job is making sure the company gets paid and profits increase.

In for profit models of health care systems, whether they run hospitals or physician groups, the same is true. Bean counters rule in a destructive way.  Bean counters become drunk with power and self importance.  

Of course, it is not only for profit systems which are ruined by the self interest motive: The cop on the beat, who actually does try to "serve and protect" becomes the forgotten man, not to mention the citizen who the cop or the doc is trying to serve. The career men, the Lieutenant Rawls and Deputy Commissioner Burrell care nothing for the people their organizations are said to be serving. They care only about themselves. They are Ayn Rand's heroes.

Maybe big organizations have to function this way--each person on the assembly line just punching in his bolt, not caring about the organism he's helping to create. People have been complaining about the loss of pride in workmanship since the assembly line was created. In medicine, each piece of a physician's job has been broken down into it's components and assembly line workers hired. The blood pressure is checked by a medical assistant. The dermatology tech cuts out the mole which needs to be biopsied. The ultrasound tech does the thyroid ultrasound. The physician's assistant uses the buzz saw to cut through the sternum, while another PA harvests the blood vessels for the leg and a third cuts down to the heart. Only when the blood vessel grafts need to be sewn in does the surgeon enter the room, takes his 20 minutes sewing in the by passes and moves on to the next of the 12 rooms he will visit that day of doing coronary bypass procedures.  The "certified diabetes educator" who may be a nurse or a dietician reviews the blood sugars and adjusts the insulin doses. The nurse practitioner listens to the patient's complaint of cough and orders a chest X ray or a CAT scan and writes a prescription for an antibiotic and sends off a blood count and maybe fifteen other lab tests the patient may or may not need. 

And, in American medicine at least, all this happens in the name of cost cutting and efficiency. But is it really cheaper to have three physician's assistants in the operating room? Is it really cheaper to have that physician's assistant ordering MRI's and CAT scans and unnecessary lab work? 

Somehow, in America, with the addition of all these assembly line workers, costs have continued to rocket upward.

"Medicine is too important to be left in the hands of doctors." An old line. 
But if not doctors, who?  Do we trust MBA's more?

The Very Modern Physician

The number is hazy but the most often cited figure is somewhere over 90% of American physicians are now employees.  The old days of the doctor hanging out a shingle and being self employed, independent,  answering to no one but his patients and their lawyers are gone.

It is true, some slice of this 90% are employed by physicians groups, self incorporated, and their employers may be other doctors, but the doctors in this 90% are now answering to someone who tells them if they are seeing enough patients, fast enough, if they are being "productive," which is variously defined by either "the body count" i.e., how many patients they see each day, or how many dollars those patients' insurance companies fork over.   "Billable hours" for the lawyer are unheard of for the modern physician. What counts is something over which he has no control, how many dollars the insurance company decides to pay.

The Phantom spoke with a young physician recently and she as happy because she had got a new job.  She is only 6 years out of training and during those 6 years she had never managed to see more than 10 patients a day; at her new job she was told she would have to see at least 18 patients a day, but she was optimistic because the new job had electronic medical record, which meant she did not have to dictate into the voice recognition systems she hated and then write a hand written note to supplement that.  She was also told that new patients, which currently take her an hour would be interviewed for their history by a "mid level" meaning a medical assitant or a nurse or a  nurse practitioner and that meant that by the time she stepped into the room with the patient all that would remain to be done would be to look over the medications and make any necessary adjustments, which she could easily do in 10 minutes.

Now, this is a very personable young woman. When she enters an exam room, she is typically smiling a rbig, dimpled smile and she has a wonderful voice and greets patients heartily, "Hi, Mrs. Smith. How are you today?" But all that will now be followed with a few minutes of medication review, analysis of how the blood sugars have responded to insulin, suggestions for changes, and a hearty  handshake good bye.

There may be time for a perfunctory glance at bare feet--feet are vulnerabilities in diabetics--but not likely for a listen to the heart or lungs and certainly no scan of the skin for melanomas or skin cancer--she is getting paid for a diabetes visit, not to save lives. 

So this modern doctor, who has vast medical school loans to pay off, is happy. She will be making more money and the basis on which she can make more by seeing more patients is clear. 

She will no longer do the sonograms on thyroids because these are not reimbursed well enough to justify her spending 20 minutes doing this, so the patients will be made another appointment with Radiology for that. The modern doctor will review this sonogram on the computer and if a biopsy is needed, she'll schedule the patient to come back for that--the patient's 3rd visit.  The biopsy is paid well enough to justify her time. But if the biopsy is not quick, if time runs out, the doctor may cut the visit short--she'll do only one of the three nodules and reschedule the patient for the rest, and the clock will start ticking again and the billing will go up.

So the modern doctor is happy. She keeps those patients moving on the assembly line, keeps plugging in those maximized billing codes and the patient is scheduled and rescheduled and she has been seen 5 times for what the modern doctor had before done in a single visit. 

The lingo for this is "RVU" or return visit unit and the modern doctor seeks to maximize the RVU's because that is the basis on which she (or he) is paid. 

Somewhere in all this, the patient has got lost.  Or, if not lost, shuffled. 

This will all be more efficient, from the point of view of the doctors and the billing department.  And none of this has been driven by Obamacare. This was happening before Obamacare and is accelerating quite apart from Obamacare. 

It is happening because medicine is now thoroughly, unapologetically commerce now. 

Heaven help us all.