“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” - Sir William Osler






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HIPAA & Fraud & Ted & Alice

Urg. I'm at the office - yes, on Saturday - and I've just spent roughly the last two and a half hours completing a multimedia educational module on the subjects of coding, chart documentation and fraud awareness. The deadline for completion of said module is November 30. In case you hadn't noticed, that's today, explaining why I am spending a large chunk of my Thanksgiving weekend here.

Welcome to the face of modern medicine.

The old fantasy of a doctor hanging out his/her shingle and going into business for himself/herself is now just that - a fantasy. Between the requirements of OSHA workplace safety regulations, ever-evolving legislation on billing fraud, and chart audits/office inspections by managed care programs, operating a physician's office really requires a large, full-time administrative staff to keep up with everything.

One of the physicians who recently resigned from the group is going into practice for himself. From what I've heard secondhand, his goal is to operate a cash-only practice (yeah, like cash patients are just lying around on the ground waiting to be picked up). The only way to avoid this bureaucratic avalanche, however, is to operate that kind of practice. The minute a physician accepts Medicare or MedicAid/MediCal, or signs a contract with a managed care organization, he has just let himself in for more audits and second-guess management than you can possibly imagine. There's no way out of it.

My father, now retired, operated his own practice for thirty years; he took it over from an elderly, well-established local physician who had practiced since the Thirties (maybe even before that). There are many great stories about his practice I'd like to tell later when I get the time, which I don't have right now. The point I'm really trying to make though can be epitomized in something Dad told me about ten years ago when the new OSHA regulations went into effect: he said there was no way he could comply with all the new requirements and continue to operate his practice; he couldn't afford it and it wasn't physically possible.

"So what are you going to do?" I asked. In case you don't know, OSHA (stands for Occupational Safety and Health Administration; it's a creation of the federal government to ensure safe workplace conditions) inspectors can walk into a physician's office for a formal inspection at any time, and are not required to supply you with any sort of warning beforehand. Being found in violation of OSHA can result in being fined up to $10,000. Per day.

He said, "I'm going to keep going for now, try to sell the practice, and if they audit me before I sell it I'm going to close it down." And he meant it. For the last two years before he sold it, he ran his practice on a knife's edge, knowing he might have to quit forever on a day's notice. He didn't have cockroaches in the exam rooms or anything blatantly dangerous or unsanitary - my dad has always been proud of his office and tried to run it in a professional way. He just couldn't keep up with the huge costs and/or investment in equipment mandated by the new OSHA requirements.

So for all of you out there, if you want to know why visiting the family doctor isn't the small-town, intimate experience it used to be, if you feel like you're just another patient on an assembly line when you go there - this is why. We can't practice medicine like that any more because documenting the physician-patient encounter is now more important than the encounter itself. The code we select to describe your visit may require more thought from us than which antibiotic or high blood pressure medicine we choose to give you.

And in case you were wondering, HIPAA stands for The Health Insurance Portability and Accountability Act of 1996. Everything clear now? Good. There'll be a quiz later. Sorry, I just took about six quizzes getting through that damned module and I can't get it out of my system.
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Mildly Naughty

Things You Can Only Say at Thanksgiving, from Shellshocking. (Thanks to InstaPundit.)
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Quote of the day, from Rebecca:

"I think I need to go make a gingerbread mansion/townhouse and then eat it."
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Parrots!

The parrots have returned! Every year around this time, we get flocks of little green parrots passing through - migrating possibly, or maybe they're just on some sort of social circuit. This morning as I pulled into my parking spot I saw a whole flock of them land on one of the eucalyptus trees that grows outside the parking structure. The trees flower and produce seed pods this time of year, and the birds seem to like the seeds.

These birds are quite small for parrots; they may be descendants of escaped parakeets or budgies, I don't know. But they're pretty green birds with red caps on their heads; they used their beaks as grips as well as their feet to move around the branches. The tree was literally dripping with birds as they fluttered from branch to branch or slid off a too-small twig trying to get to the seeds. They're loud, too. They chattered away as bird after bird (late arrivals to the feast) flew into the tree trying to get in on the action.

Finally the whole flock burst out of the tree in an instant, off to South America perhaps, or just trying to find another meal in a tree. I headed downstairs to the ground level to walk over to my office, and as I stepped outside, I saw the ground covered with red seed pods jettisoned by the parrots. I felt that I had been transported to a tropical, exotic location instead of midtown Los Angeles - for about fifteen seconds. Still, that's a pretty good feeling for a weekday.
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Thanksgiving

The folks are late, Dad had to run to Home Depot before they head over here for dinner (long story). Looks like I've got a little time to blog after all!

Heather Havrilevsky has an essay on Thanksgiving that I thought was worth reading; James Lileks has a wonderful one. If you're killing time while dinner gets ready, check them out.

Speaking of dinner, I am doing a turkey breast in the Crock Pot, since there are only three of us (it's really good and astoundingly easy). Also, baked potatoes and broccoli. It is a bit stripped down, but my folks are grateful not to have to cope with cooking the meal; I really don't think they'll care.

I went to church this morning with my friend Jim. St. James', my church, is Episcopal; we have a 9 am service every Thanksgiving. I try to go for several reasons: because this really is a religious holiday, or at least it started out that way; to see my St. James' friends who have gotten me through some hard times in the last six years; to remind myself that this holiday is NOT about food and it is NOT a license to pig out.

I am grateful for my family and their continued good health. My father had a stroke a year and a half ago and has made a wonderful recovery. My sister now has three terrific kids; my newly engaged brother and his fiancee are spending the holiday with them.

I am grateful for my job. Yes, I really am, most of the time. My last patient of the day yesterday was a woman whose mother died suddenly on November 24. I saw her for some grief counseling and to give her some time off work. Both her parents, now dead, were my patients. It really is special to take care of an entire family, and to be able to really understand where a grieving person is coming from when she talks about her loss.

I'm grateful for all my friends, on-line and off, and for all the encouraging emails and feedback I've gotten from you. Thank you!
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Here is Chuen-Yen's latest dispatch from Malawi. If you like dogs, you won't like this post:

Greetings! Here is some Houseboy Wisdom:

�Dogs, cats and chickens can go on the bus.But if you want to take a goat some place, you must hire a taxi.�
-- On transportation of animals

�I cannot wash it in your bathtub. It is a dog and you are a person.�
-- When asked to wash Molly and Notti in the bathroom with human shampoo, instead of outside with laundry detergent

It�s hard to be a dog in Malawi. When I took Molly and Notti for a stroll, unarmed people avoided us by crossing to the opposite side of the street. Several tentative machete-wielding field workers braved passing on the same side, though safely out of reach. A few people pointed to the dogs and mimed bites to their extremities.

Later in the day, Gift informed me that burglars had killed a neighbor�s dog. His friend, their gardener, found the dead dog with three bloody gashes on its shoulder. Gift demonstrated the locations of the wounds and how they were most likely inflicted. He also noted that the neighbor�s two other dogs were still alive, but would probably be poisoned by thieves in the future.

Unlike obsessive-compulsive dog pampering Americans, few Malawans understand the concept of dogs as pets. Dogs protect property and are universally mean to strangers. A few crazy foreigners are known to let them in the house, feed them table scraps and take them into town on leashes.

With the help of several little Adventists, I bathed Molly, Notti and three unclaimed puppies yesterday. This event consumed nearly two hours, an entire bar or soap and countless liters of tepid water. To Gift�s dismay, it all occurred in the bathtub. I have never heard Gift laugh so heartily. Incredulous that anyone would share space with an animal, his response was to thoroughly disinfect the bathroom. I wonder if it�s harder to be a person or a dog in Malawi.
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It's my birthday today. My "Jack Benny," as one of my friends referred to it (one of Mr. Benny's running jokes was to claim his age as thirty-nine for his entire career).

Last night my office mates gave me a nice little surprise party after hours, complete with champagne - woo hoo! - and white Zinfandel. For those who don't like champagne. Some of the office staff preferred it. Cake, flowers. I really hadn't expected it, and a lot of people showed up - in fact almost everyone from all four offices here. Seeing all those people wanting to wish me a happy birthday meant a lot, almost took the sting out of this particular birthday.

I spent some time trying to remember what I did last year for my birthday... finally I remembered. It was a cold, windy Monday night. We were having Santa Anas, just like now, but it was much colder. I met two friends at the Formosa Cafe in Hollywood for drinks and dinner. It was quite fun. The Formosa is one of those old Hollywood dive landmarks that's been around for almost seventy years, I think. The original eating area was made out of a boxcar, which is still there as part of the restaurant.

Today is our big annual office Thanksgiving potluck, so I will go to that and have a nice lunch. Tonight is a school board meeting which I have to attend; I'm one of the trustees for the St. James' parish school and we have just finished our search for a new head of school, so I have to be there (oh, the decadence). Then I'm stopping off at a friend's house for a quick drink, and so the day will end. I think this is the best kind of birthday. I usually don't take the day off for my birthday - I work, but it's nice to have these little celebrations scattered throughout an ordinary day.

At least it's not on Thanksgiving this year. I hate that.
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Another day, another movie.

I was at the gym again, watching TCM (Turner Classic Movies cable channel). At 5 am it's either that, the news, or the Andy Griffith show. As an aside, did you know that Don Knotts won five Emmys during the run of that show? Five? It's true. I mean, one Emmy I can see, but five?

Anyway. This movie was called "The Bad Man." It involved a young, heroic Ronald Reagan and his uncle (Lionel Barrymore) on a ranch. They owe ten thousand dollars on their mortgage and are about to lose the ranch. A beautiful married woman and her dastardly husband come to the ranch - a dude ranch? who knows why they're there - and Ronnie and the young woman fall in love. A Mexican bandito, the "bad man" of the title, shows up to rob everyone but then decides to make things nice for Ronnie; apparently they're pals from way back when. I didn't get that part clear.

Some local hick girl is in love with Our Hero, but the bandito palms her off on the ranch foreman. This other girl is the daughter of the local banker who holds the mortgage on the ranch. (Confused yet?) The bandito extracts $10,000 from the banker at gunpoint (I guess bankers just carry around $10K in spare change), gives it to Uncle Henry (Lionel Barrymore) and then orders him to give it to the banker in exchange for the mortgage. (Bandito to banker: "You got paid, didn't you?")

So the bandito and his gang take off with the dastardly husband, who is to be killed so that Ronnie can marry the girl; but the husband escapes, sneaks back to the ranch, struggles with Ronnie while trying to kill him, and is finally shot dead by the bandito who just happens to show up at the right time. I could almost hear the plot points screaming in agony by this time.

I forgot to mention that Uncle Henry can't walk and spends the entire movie in a wheelchair. The film ends with the bandito taking Uncle Henry for a thrill ride by tying his wheelchair to his horse and going for a gallop. (I swear this is true.)

Lesson to be learned? The next time you put down the current crop of movies and say, "Oh, they made them so much better in the old days" - THEY DIDN'T.

Be that as it may, I still had fun watching "The Bad Man" [1941] (UK title: "Two-Gun Cupid" (ugh)). The cast was memorable. As mentioned above it starred Ronald Reagan, who I always find fascinating to watch in films, just knowing what lay ahead of him in his career. Lionel Barrymore - what the hell was he doing in this thing? Probably paying the rent. The dastardly husband was played by Tom Conway, best known for starring in a series of B mysteries in which he played a character called "The Falcon" (a low-rent version of Leslie Charteris' character Simon Templar, "The Saint"). I'd recommend any of the "Falcon" films if you happen to run across one on late-night TV. The ranch foreman who got the hick girl was played by Chill Wills; the bandito was Wallace Beery, clearly playing a watered-down version of his famous Pancho Villa role in "Viva Villa!" (1934). The neglected wife who falls in love with Ronald Reagan was played by Laraine Day, who later turned up in the Dr. Kildare film series as the nurse love interest for Dr. Kildare.

As I said, analyzing the cast was more interesting than the movie. I could do this stuff all day.
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Lately I've been stopping by to visit our office manager almost every day. Her office is across the hall from the patient care area, in the administrative section. Sometimes we chat about non-work-related topics like food, holidays, and weekend activities but more and more often we sit and dissect the workings of the group.

This week I came back on Tuesday from a couple of days off and was greeted by our manager with the news that one of our doctors is quitting the group. He's the second one in two weeks to announce that he's leaving. A third initially threatened to leave but later changed his mind and elected to stay. For now. I, for the record, have no intention of leaving. I like it here, and I really don't think things are going to be that much better anywhere else I might try to work. We are constantly pushed to work hard, be more productive, etc. but in this managed care climate, I imagine every medical group, and for that matter, every solo physician, is faced with that dilemma. The insurance companies have pretty much exhausted any merger possibilities and now are trying to tighten their belts, raise premiums and do anything else they have to do to survive. We, and the patients, are feeling the pinch.

On my good days I look at this as a challenge, like learning to juggle. I try to see if I can do things a little faster, squeeze in one more patient or one more phone call. One more ball added to the workload, requiring a little shift, a bit of an adjustment, and then things will keep spinning along. Join another committee? Another ball. Get assigned to reviewing referrals? Another ball.

The problem, if you will allow me to continue the metaphor, is that the balls are being taken from a shrinking pile marked "Personal Life." Dating? Forget about it, I haven't been on a date since I moved to Los Angeles eight (Eight! Jesus!) years ago. Weekends? If I told you how many Sunday afternoons have been spent here you'd scream at me. Weeknights - spent here.

(Above portion of post written at start of working day... terminated till after hours to avoid seeing patients in tearful mood of self pity...)

I'm not the only one in this dilemma, I know. And doctors aren't the only ones feeling pressure to perform either, this happens in every profession - I know that too. But lately it seems we get no good news, only bad. I present you with an email I got from my good friend who works down the hall from me; she practices endocrinology and internal medicine, and is supposed to be working part time. She seems to stay just as late as I do though, and she has two small children. (How do people with kids do this job? Damned if I know.)

At the Friday meeting [which I missed - A.] we got appointment scheduling guidelines...their "expectations" include
- "comfortably" seeing 3 pts/hr (FTE = 31.5 hrs = 95 pts/wk)
- given a 10% no-show rate, should book 105 pts/wk (23/d) (figuring I book 2 hrs less per day, I figure I should book 6 less - 17/d - I'm there!!)
- frozen slots (in my practice, that means lunch & after the end of the day)
- see other folks pts & all schedulers should have access to all schedules
- review your schedule 2 days in advance
- call your patients to ask why they're coming in & forstall unnecessary visits or be better prepared
- review master schedules q 6 mo

It irritated me, but then I think I'm doing my job. Tho, according to my eval, I'm only doing about 97-103% of expected, which is 'adequate'. Sorry, I can't walk on water with these shoes. Come another day.

Enough. I don't think anyone can work well under this kind of constant pressure. It really got to me today; I wound up blowing up at a patient who walked in, without an appointment, at 12:55 and insisted on being seen immediately. We offered her an afternoon appointment and she started yelling at my receptionist. I stalked out and called her a spoiled brat - yes I did - in front of a waiting room full of patients. And I'm not sorry I did it, either. I did wind up seeing her, just to get her the hell out of the office.
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Suddenly I'm Channeling Jane Austen

This morning I was seeing a patient, who is pregnant, for an exam (for an unrelated issue). When I asked for her due date she replied that her "estimated date of confinement," a term she'd clearly picked up from her OB, was in May of next year. I suddenly realized that the term "EDC," which is an abbreviation doctors use all the time, stands for just that - "Estimated Date of Confinement." It's one of those acronyms I got into the habit of using without thinking about its meaning.

The patient: "I thought 'estimated date of delivery' would make more sense, but that's the way they [the OB] said it."

I responded: "Medicine has archaic terms that still crop up even when you don't expect them. 'Confinement' used to be the term they used for delivering a baby. We still say 'EDC' even though it doesn't really make sense anymore."

We both laughed as I added: "It's like, 'She's pregnant. Confine her!'"
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Last of the Leonids

For those of you who have an astronomical bent, the peak of the Leonid showers for 2002 and, in fact, for most of the century will be tonight (or rather, early tomorrow am) from 2.30 to 2.45 PST. Go here for further information. I would love to see this shower, but living in the middle of LA can cramp one's observing style due to light pollution. I may get up and trek off somewhere isolated so that I can get a better view - and wind up getting assaulted, no doubt. But be that as it may, I have seen a meteor shower or two and I can vouch for the stunning effect of watching many little fireballs streaking through the sky. The only thing I'd like to see more is the aurora borealis, which I have not yet managed to see - but hopefully someday I will (around the same time as I compete in the Iditarod).
UPDATE:
My father considerately called me at 2:30 am asking if I wanted to get up and see the Leonids; I opted out. (For the record, I did ask him to call me.) The moon was too bright to see much of anything.
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PETA, PETA, Pumpkin Eata

It's amazing what a little creative digital picture altering can do...

The good folks at PETA won't be very happy about this. (snicker)
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Whew!

I will never try to add anything fancy to my template again. I didn't get any email help from blogger and finally had to print out a sample template and go through everything line by line... but at least it's working again.
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Here again is a post from my friend Chuen-Yen in Malawi. She has just been to a wedding, which sounds more entertaining than your average American ceremony (or at least different):

Greetings!

I have finally experienced one of the most popular Malawan events � a wedding. The bride was the granddaughter of a non-compliant patient. She was marrying a local grocery boy. I showed up only 15 minutes late (far too early) with my gift wrapped in a big brown x-ray envelope. The venue was the bride�s family�s house. In their dirt courtyard, surrounded by crumbling walls with projecting shards of glass, rows of hot metal chairs faced a decaying concrete structure. Colored toilet paper and a few
balloons decorated the porch, where the couple would be displayed on the family�s couch. An unsteady table displayed gifts wrapped with newspaper, plastic bags and one with an x-ray envelope. A few chickens and a goat picked at a pile of nearby refuse.

As everything was in Chichewa, I probably misinterpreted most of the ceremony. But it was clear that some of the ritual revolved around soliciting frequent donations from guests. There were even �cahiers� to tally the gifts and make change in case you didn�t bring the right denominations. The bride and groom were showered in small bills every time the announcer gave a certain cue, which always stimulated lots of hooting.

Between fund raisers, candy was passed around (one piece per person please), people feasted on rations of oily salted rice and then had a sliver of cake. No utensils were involved. Hence, buckets of water were provided for sanitation. There was also some dancing � shaking of the butt without
moving the upper body � which I am told one can become proficient at in about 3 months.

During the celebrations, many people approached me for medical evaluation and a chicken flew into my head. Just after that, with much hooting, it was announced that 4,500 Kwacha and 12 gifts had been collected. Everyone had a great time. I admitted the bride�s grandma to the hospital the next
morning and saw a few of the guests in my clinic. Everything is amusing here.

Hope all is well over there.
Chuen-Yen
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Well. Here's an interesting story: Gun-toting Gomer Gets Ground Squirrel. Apparently the rodent in question was in a state of permanent rage and was hassling the town of Knutsford, England. Perhaps it was Irish:

LONDON (Reuters) - A squirrel which terrorized a British town by attacking people has been shot and killed by the grandfather of its latest victim.

Geoff Horth, enraged by the squirrel biting his two-year-old grand-daughter Kelsi Morley on the face, took up his airgun and hunted down the rogue rodent, the Sun newspaper said on Friday.

"When I tracked him down I was surprised how big he was. He came down a tree and headed for me, but I shot him before he jumped," the 61-year-old school caretaker told the newspaper.

The bad-tempered squirrel's reign of terror in the town of Knutsford in central England had made parents frightened to let their children out to play.

Somehow it all sounds like a third-rate horror movie.





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Bwahaha!
Australian journalist Tim Blair, freshly returned from a coast-to-coast trip to the US, does a first-rate job of trouncing Michael Moore and his column regarding this week's elections. I've never been able to stand Moore, but in this column he was even worse than usual. I wonder what jerry-rigged theory he's going to come up with to explain why Bush was supported in these elections rather than "shellacked" (as Moore would have it).
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Which Founding Father Are You?

Try this quiz to find out. I'm George Washington!

You are the most reliable creature on the face of the planet. You're not the most creative, but inspire great loyalty because you are physically incapable of not keeping your word. People set their watch by you. You are often the one friend in common between two blood enemies.

Thanks to The Fat Guy for the link. (Really, that's what he calls himself.)
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The Many Faces of Alice

Check out googlism.com to see who you might be. It's fun!

Here is who Alice is, among other things:

alice is alice is not alice and
alice is all broken up
alice is stage struck
alice is surprised by tweedledee & tweedledum
alice is pressed for an answer
alice is talking again
alice is home
alice is currently under construction
alice is on the ball
alice is changing all the time
alice is probably the most unpredictable game available today
alice is wonderful
alice is sometimes a film student
alice is in unix land
alice is dead
alice is back
alice is active in the hospitality industry and has spoken at many industry highlights including mufso
alice is a department head at acme fabco whose business has been adversely affected by competition from imports
alice is nothing more than a gigantic pattern
alice is open source
alice is stunning
alice is back from canada? but not separated from husband
alice is a comedy about the shaky relationship between an incorrigible scoundrel of a novelist and his devoted fan
alice is a giant and stuck in the white rabbit's house
alice is an alicebot engine written in c++
alice is trying
alice is gaining importance
alice is the leading character of the book
alice is several years older
alice is one of the smallest commercial wheeled autonomous robots in the world
alice is bored and a bit sleepy
alice is a strong advocate for farmer's markets and for sound and sustainable agriculture
alice is back in wonderland
alice is almost too much
alice is one of the most anticipated games of the year and will surely be a competitor for the game of the year award
alice is also os x compatible
alice is the name for ohio university's library catalog
alice is 5�" tall

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Arrr!

I have to confess. I have a secret crush on Robert Newton - a not-so-well-known British actor who starred in various films from the 1930's through the 1950's. He had a respectable stage and TV career as well; his film roles include Inspector Fixx in "Around the World in 80 Days," a co-starring role with Burt Lancaster in "Kiss the Blood Off My Hands" (ugh), one or two Hitchcock films, and a ne'er-do-well who goes good in "The Beachcomber" - but his best-known role was as Long John Silver in Disney's 1950's version of "Treasure Island." He hammed the hell out of Long John, but he did such a good job that viewers for decades have associated him with piratespeak. Every "arr, matey" you hear originates with his performance.

Why do I bring this up? Because Robert Newton recently impacted my job. No, really. I ran across a column by Dave Barry promoting National Talk Like a Pirate Day and got carried away.

Ask the average person to talk like a pirate and what will you hear? What do you hear in movies and on TV?

"Belay that, ye scurvy swab!"
"Avast there, ye landlubber!"
"The whiiiite whale!" (No... wait... that was another movie...)
I even heard this line delivered by Anne Heche in "Six Nights, Seven Days": "Pirates? As in 'Arrr'?"

At any rate, Dave Barry did a marvelous job of painting the attractions of using piratespeak on the job. I quote:

BOB: Avast, me beauty.

MARY: Avast, Bob. Is that a yardarm in your doubloons, or are you just glad to see me?

BOB: You are giving me the desire to haul some keel.

MARY: Arrrrr.

I immediately vowed to institute Talk Like a Pirate Day at my office. I recruited a willing crew after I sent some emails around and did my best Long John Silver imitation for the staff. Once they'd heard me describe a recalcitrant patient as "a scurvy landlubber," I found lots of willing participants. Even our dermatologist got into it; it's been nearly two months since Talk Like A Pirate Day and she still sends me emails addressed to "Matey." It was quite therapeutic to spew some nautical expletives at the HMO's and still say nothing that was obscene.

So here's to you, Robert Newton! Your legacy lives on. Arrr!



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Go here for more information on Measure 23 in Oregon. This weblog is run by an internist (like me) who has far more info and links on his/her blog than I do. I don't know yet whether the measure passed, but if you're interested in the overall debate this is a good place to start.

Having a busy week. More later.

No, I haven't made any progress on my writing. But thanks for asking.

ADDENDUM: Measure 23 was defeated.
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Tomorrow the state of Oregon is voting on an initiative designed to provide the entire state with free health care - Measure 23. This measure supposedly will cover the state's healthcare costs by raising business and personal taxes to add to Oregon's share of the Medicare pool (the drafters claim that this will be offset by the fact that businesses will no longer be obligated to purchase health insurance for their employees, and that individuals will not have to pay co-pays or their share of insurance costs). The measure states it will cover everything. EV-ERY-THING. This means massage therapy, acupuncture, hospitalization, mental health, drugs.

Let me just say this, people: it won't work. It will not work. I can give you a few reasons:

1. In Europe, with similar plans, drug formularies are somewhat restricted, and, more importantly, national healthcare systems can drive hard bargains with pharmaceutical companies, which keeps their costs down to a certain extent; the US pays more for drugs than anywhere else on earth.

2. Corporations will hightail it out of Oregon faster than you can possibly imagine - there goes your tax base.

3. Everyone on the West Coast at or below the poverty line will move to Oregon ASAP.

4. Everyone in Oregon will immediately start requesting counseling, acupuncture, massage therapy, etc. They will start requesting the most expensive drugs on the market - granted, they work and work well, and they often keep people out of the hospital, but I really think the expenses of this project will balloon faster than anyone backing this measure can possibly imagine. I can hear the patients now - "Hey, doc, I pay my taxes. I've already paid for this. Why can't I have acupuncture for my (hangnail, stress, weight loss, back pain, etc.)?"

5. Get ready for long waits. The truth is, you always pay with health care. You either pay with money or with time. Look at the UK health system if you don't believe me, or Canada's. I have several physician friends who are Canadian and chose to come down to the States because of their frustration with the Canadian health care system. You may be able to get acupuncture or massage therapy, or counseling, for free - but if you have to get on line and wait three months for it, is it really going to help you?

Don't get me wrong, if Oregon wants to experiment with this system, go for it. You go first, guys. We'll be standing on the sidelines watching. If this measure passes it will be implemented in 2005; it'll be interesting to see what happens over the next five years.
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Got a blog recommendation for you. Check out Ernie Hsiung at his blog site Little. Yellow. Different. This guy is Chinese, he is a computer programmer, he lives in the Bay Area, he is gay and he is frickin' hilarious. Four out of four stars.
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Dancing Pirate??

Well, it is now National Novel Writing Month and, no surprise, my attempt at participation isn't going very well. It seems you can't just sit down and write a novel. I never really expected to get through 50,000 words, so I'm just trying to look at this whole experience as a writing exercise and to get some writing done every day. (Apart from this blog, which is a hell of a lot more fun.)

I set aside all day yesterday to write, only to find myself discovering more and more ingenious ways to pass the time doing other things. One thing I did last night instead of writing was to sit down and watch a movie called "Dancing Pirate" that I bought from Sinister Cinema some time previously because it starred Frank Morgan - one of my favorite character actors. I'd never gotten around to watching it, but with a deadline hanging over my head, what better way to waste 90 minutes?

Well. "Dancing Pirate" turned out to be an early Technicolor musical starring a dancer I'd never heard of named Charles Collins. It was not very good. In fact, it's pretty bad. The movie is set in the 1820's and starts out in Boston, but ends up in Old California. How does this happen? Strenuously. In the first fifteen minutes we get Mr. Collins (who plays a dancing teacher) doing a silly little dance around a room putting candles out at the conclusion of his dance class (he's teaching the waltz), after which he steps out onto the city streets and promptly gets knocked over the head and press-ganged onto a pirate ship. We then see the old routine of a ship model sitting on a map, followed by a moving line that tracks south to Cape Horn and up the other side of the Americas to California in fifteen seconds flat - that must have been one fast pirate ship.

At this point, Mr. Collins jumps ship to get away from the pirates and walks into the town. Unhappily for him, a local shepherd has seen the pirate ship and warned the town, so first he nearly gets his head blown off and then the town wants to hang him as a pirate. I had mental whiplash at this point from following the guy's adventures. But, as with most musicals, having laid the situation in place the action comes to a screeching halt for several dance numbers. The mayor's daughter wants to learn how to waltz, so he teaches her. At first she is affronted, but then she figures out that she likes to, uh, waltz. The stage is set for a happy ending at this point but we've got another 45 minutes to get through, so the Bad Guys from Monterrey down the coast (up the coast? I don't know) show up. Their leader, the Capitaine, wants to marry the mayor's daughter and get control of the rancho which her father, Frank Morgan, owns. They arrest Our Hero under the pretext that he's a pirate - again?? - but the heroine, Serafina, offers her honor to marry the Capitaine on the agreement that they will release Mr. Collins. Our hero (that would be Collins), having had the forethought to befriend a local Indian in the prison, leads his friend and fellow tribesmen in a remarkably fey wardance and thus incites them to overpower all of the Capitaine's militia so that he can break into the church, stop the ceremony, overpower the Capitaine in a swordfight despite the fact that he has no sword (I am not making this up), lead the town in one more samba dance and then lead the heroine into the church. End of movie. God Almighty, what a mess.

A few postmortem comments here. First, Charles Collins, as you will see if you check out the IMDB.com link above, starred in a few movies but not many. From having seen his dance numbers in this thing, I can tell you with a fair amount of confidence that he was being groomed as a Fred Astaire wannabe. He didn't quite cut it, mainly, I think, because the choreography just wasn't up to snuff. I'm no judge of these things, but the guy seemed to be a technically adept dancer. The first two numbers here, though, were enough to put paid to his film career: in the first one (I alluded to this above), he tapdanced around the room to the tune of "Yankee Doodle" (his signature tune throughout the movie) snuffing out candles. Actually, he PRANCED around the room - he didn't dance. Then, when he's pleading for his life in California and trying to prove that he's a dancer, he dances around the gallows where he's about to be hung, with a noose around his neck and his hands tied to his sides. Again, I am NOT making this up. Blair Witch has nothing on this, people. But for those MST3K fans reading this - and I know that you're out there - you will no doubt be pleased to know that Mr. Charles Collins surfaced playing a role in Master Ninja I in 1984 (at the age of 80). He died in 1999.

Two further notes: First, in this film Frank Morgan played his patented blustering ignoramus character that he was to repeat to greater fame, three years later, in "The Wizard Of Oz." I would just like to say that, if you want to see him at his best, rent "The Shop Around the Corner" and watch him do his thing opposite James Stewart. This is one of my very favorite movies and you will NOT be disappointed. Second, one of the chorus dancers in this film was a Rita Cansino dancing with her father, Eduardo Cansino, and their family dance group the Royal Cansinos. She was later to achieve much greater fame as Rita Hayworth. Unfortunately, the print quality was so bad that I couldn't tell which of the chorus dancers she was.

posted by Dr. Alice at #

 
Gather round, boys and girls. I have a mildly ghoulish story for you, appropriately as today is Dia de Los Muertos (Day of the Dead) here in Los Angeles. This is the Story of Why Alice Named Her Blog "Feet First."

Years ago, when I was a high-school student and trying to figure out what I wanted to do when I grew up, my father (also a physician) figured he'd try to help me along by arranging for a tour of the hospital where he was on staff. A primary care doc himself, he wanted me to consider something in medicine where I wouldn't actually have to deal with people - thus he sent me on a tour of the pathology department.

It was more fun than you'd think. The doctors were rather social actually; not wildly busy, they seemed to enjoy a chance to talk to an appreciative audience about what they did. I've liked pathology ever since - this came in handy when I got to med school - but still I wound up in primary care, same as Dad did (I just liked it better). The day of my visit I got to wander around, peer at slides, and look at a couple of specimens and hear the patient stories behind them. You know, mildly gross-out stuff but not that gross. I got my first smell of formaldehyde (ugh), listened to the head pathologist bitch and moan about hospital administration, procedures, and policy (I was no stranger to this either, as I got a lot of that from my dad every dinnertime), and finally they showed me the morgue.

"Morgue" was an overstatement, as most hospitals don't have that much body storage space - they don't need it unless you're in a trauma center or a big academic hospital. Unless you're doing an autopsy, and most patient deaths don't require one, the mortuary will trot along and pick up the body right quick. What I recall is seeing a few storage cases where bodies are kept until picked up or the autopsy is completed. These were cold storage, as usual, but they weren't fitted with drawers as you often see in TV shows; instead they had hatch doors like you'd see on a submarine. They opened one, I peered in (there was no body resident at the time), and then I saw a small label posted just above the door.

The label read:

FEET FIRST

posted by Dr. Alice at #