Category Archives: money

‘Concierge’ Medicine – A De Facto Manifesto

My blogging output has been at an all-time low since moving to Europe.  Who knows why…this place is such a bore.  I continue to hack away at my book, which never seems to get close to done – the literary equivalent of Sisyphus’ ever-rolling stone.

The other day a reporter contacted me to hear my thoughts on so-called “concierge” medicine.  It was a timely query, since I’m considering a loose offer to join a concierge practice back in the States.  In my email reply to him, I found myself writing my own little manifesto on the subject.  A treatise, if you will.  A declaration.  A primer? A resolution, a promulgation…

William Osler (1849 - 1919), Professor of Clin...

I have a idea...how 'bout I actually know who you are, AND care about your medical issues?

 

I’m a big believer in concierge medical practice, although I use the term “concierge” only as a nod to already-established norms.  Really ‘concierge’ medicine is a throw-back to true primary care medicine before it was ruled by other industries.  So the idea isn’t new.  It’s old – old as William Osler and Johns Hopkins and William Carlos Williams.
This industrial “take-over” I mention isn’t entirely due to craven insurance businessmen.  It’s also due to the allure of “Wal-Mart” pricing that so captivates Americans.  I suppose you’ve heard the adage that as a consumer, you can only have 2 out of 3 options in the market: Fast, Good and Cheap.  If you want something fast (hamburger), you can get it cheap (McDonald’s) but it won’t be good.  Or, you can have it fast and “good” (quality, taste, etc), but it won’t be cheap (maybe, Red Robin?).
This principle is true in medicine too.  Americans, over the past 20 years, have been trending toward Fast and Cheap medicine, just like they want clothes, household goods, food, etc. quickly and cheaply.  Hence, the rise of WalMart, which provides easily acquired things of questionable quality.
Concierge medicine isn’t “cheap,” by WalMart standards.  It requires real cash investment.  But it IS better.  And, while there is little problem with wearing nondescript, zero-style golf shirts to work every day, primary care is different.  We’re talking about your life, here.  Not only are you likely to live longer and healthier with good primary care, but it really is cheaper over time because it is so effective in offsetting gigantic medical calamities later.
I dispute the notion that no one can afford concierge medicine, by the way.  Most people in the richest nation on earth perceive they can’t afford it, but really can.  I blame this perception on the invention of the 10-dollar co-pay.  This idea was such poison in American medicine.  It made medical care seem like the equivalent of a few iTunes, or sunglasses from a roadside gas station – just another in the ocean of cheap, disposable and generally worthless products. Yet so many Americans shell out enormous amounts of money on alcohol, cigarettes and fast food.  They don’t think twice about coming up with over a thousand dollars to fix the clutch on their car, or to trick it out with lights and racing wheels.  But when it comes to good, relationship-based primary care, they resent anything more than “10 bucks.”
I’m currently in a line of work that provides “free” care to everyone (the military), so at the moment I have no vested interest in the above comments.  But I continue to feel strongly that it is not immoral to require a reasonable, even significant, amount of money for true primary care, especially when obtaining that care may require cutting out things that are terrible for your health.  I see major problems with a medical system that tries to provide unlimited access, especially when coupled with zero perceived cost for that access and care.
More health care is not better health care; worse, it can be dangerous.  On a daily basis, people needlessly lose breasts, prostates (read: sex life), resistance to microbes, and countless other quality of life measures in the process of hunting down phantom maladies or responding to false-positive tests.  High-quality primary care offers good, analytically based work ups of genuine symptoms that justify that work up.  NOT investigating something further can often be the best medical care available.
I mention ‘analytically based’ decisions because most mid-levels (a cost-cutting invention in American medicine) are trained to provide algorithmic decision-making:  that is, if X symptom, then Y action with little analysis involved.  recipe medicine.
Often algorithmic medical decision-making is just fine, but it easily leads to over-testing and over-treatment.  When it comes to possibly dying from cancer, for example, most of us want someone who knows us, knows how we communicate, and what is important to us (e.g. dignity vs. “full court press”). Further, we want that same person to be well-trained in weighing the risks vs. the benefits of treatment vs. non-treatment, based on the latest available medical knowledge.
Doctors seeing 20 patients a day can’t provide this adequately.  Mid-levels are not trained to provide this type of risk-benefit analysis, and don’t have the hours of training experience even if they wanted to.
Disclaimer:  I’m speaking in generalities here; there are fantastic PA’s and NP’s out there, many of whom are compassionate and professional; better than many physicians.  Most I’ve met are smarter than me.  But in general, the care from a mid-level is fundamentally of less quality because the training of a doctor is an average of 3 times more than any mid-level (roughly 3,000 hrs vs. 12,000).  This differential limits mid-levels to algorithmic, rather than analytical, decision-making.  When it comes to your health care, the mantra should be “reason, not recipes.”
These days, you can’t get this care from HMO’s (Group Health in Seattle is getting very close), you can’t get it from mid-levels.  The only place I know where you can get this level of care, is in a ‘concierge’ practice, where the benefits of the increased cost are immeasurable.

DIE-Tunes

I believe I have just witness the beginning of the death of iTunes.  As much as I’ve tried and tried to like iTunes, I can’t express how happy I am to see a true and valid competitor emerge to thwart them.  And, I think this will DESTROY them.

Amazon, you rule.

iTunes Icon

Something Tells Me I've Just Violated A Copyright By Posting This Logo.

Now you can buy Mp3’s from Amazon.com and – here’s the sell – store your tunes to the cloud, not on your own hardware. I’ve been begging (in my head) for this for YEARS.  The cost and hassle of trying to constantly figure out where to store my songs and shows that I’ve downloaded from iTunes has been one endless headache.  This has as much to do with the fact that I’M MAKING A GENUINE EFFORT NOT TO STEAL THEN (in all honesty, this is my big mistake).  Being legit, I’m constantly plagued with copyright protections on iTunes products that makes storing and moving MY copies of digital media almost impossible.

The obvious solution (one that still supports the artists and their decadent renunciation of most human moral codes) is to simply quit making me store the songs in the first place.  Just stream them from some central server that I never even deal with.  Amazon Cloud Player (actually real, actually available, actually currently playing 1 of 100 of the top trance tunes of 2011 that I just bought as a collection for…9 bucks) does just that.  Finally.

One example:  I had a tiny netbook, with virtually zero hard drive space.  So I tried to store all my tunes (and shows) on an external hard drive.  Then I switched computers, and wanted to move that data.  Tough.  Sounds easy, but it ain’t.  To Apple, it looks like I’m stealing them, or selling them in some virtual dark alley, furtively looking over my shoulder and waiting to hear Hugo Weaving bellow, “Mr. ANDERSON!”  If I’d just legitimately STOLEN the damn songs in the first place, I could play them wherever I wanted, moving them like so many Word files.

Zeus with a laurel crown. Gold stater from Lam...

SW101: God Of Ruined Mp3 Players.

 

Another example:  If ruining ipods (usually by jogging in the rain) was a God-like attribute, I’d be warming up a U-haul for my move to Mt. Olympus.  I just sorta never believe water is actually bad for anything.  It’s a swimmer thing.  Anyway, my iTunes can only be played on 5 players unless I “de-authorize” a player.  This sounds find, but how do I de-authorize a player that has suddenly transformed into really unique thin mint?  I can’t even turn it on long enough to de-authorize the glorified aluminum can.  Same for my original computer that held the results of my first foray into iTunes psychosis.  It suffered a massive “heart” attack at some point.  That’s 1 authorized player I’ll never get back.

Six hard disk drives with cases opened showing...

Hard Drives, Hard Drives Everywhere...

 

Now it doesn’t matter.  My tunes are floating out there, in the beloved cloud.  Free from the confines of my cheap, inefficient hard drives that never seem to have enough space.  With Cloudplayer, the tunes stream, so presumably, copying them illegally is much harder.  So, I would hope that Amazon will be HELPFUL when I try to use one device or another, or when I mistakenly put my Mac Mini in the microwave, expecting a nice melty pizza in 2 minutes and 30 seconds.

Plus, it’s Seattle busts Cupertino.  Kurt Cobain vs. The Grateful Dead.  The Sound vs. The Bay.

Die.  Die Tunes.  You had your chance, Appletini.

XBox – A Medical Necessity

“Dr. SW101,” Says the curly-haired assistant, “will you sign this memo.”

I don’t look up.  As usual, I don’t read the memo, reaching for the closest pen and signing as fast as possible.  I look up at him, smiling cheerfully.  “What’d I just authorize?”

This is a photo of my Xbox

Image via Wikipedia

 

“Oh, you just told General Forth that the unit has medical need for 6 additional XBoxes.”

I pause, wondering why I’m so morally opposed to all paperwork that I can’t bring myself to even look at paperwork unless I absolutely have to.

“Xbox,”  I say, brows furrowing.  “Do you get ‘em at the pharmacy?”

“No!”  He says, cloyingly earnest.  “You’re SO funny, Dr. SW101.  You should write a blog!”

“I do.”  I say, feeling sardonic, looking dour.  I reach for Volume I of Harrison’s Internal Medicine.  I lick a thumb and start flipping through the thousand-page tome.  “Hmmmm, Xbox.  Nope.  Nothing here.”

Assistant waits dutifully, no doubt inwardly rolling his eyes while clutching his well-typed letterheaded memo, with my signature still drying at the bottom.

“OH!  Right.  I’m only in Volume I.  Stupid me.  I should be in Volume II, where the X’s are.”  I pause.  “Just a minute,” I say, reaching for the second book.  A few minutes of earnest searching, “Nooh.  Darn.  I just don’t see anything talking about how XBox is an accepted therapy for anything.  Not even my favorite disease of all time – mitochondrial infectitis.”

“You’re kidding, right?”  He says, now looking worried.  “We can get the Red Cross to buy XBoxes for the unit if you say they’re medically warranted.”

“So, my patients – most of whom have seizure disorders, PTSD and post-combat anxiety – can sit around all day blowing each other up and staring at flickering lights?  Maybe I should prescribe a Rave too, so we can add drugs to the strobe lights.  Or would they be used for the Xbox version of Myst or something?”

Regions of the brain affected by PTSD and stress.

Bzzzt. What I need is some rapidly blinking lights and simulated death right now.

 

Assistant gets all serious, fearing the loss of his beloved memo.  He starts reading some of the Pulitzer Prize material, “Gaming has become a central element to the Soldier’s past time.  When they return from war zones, the lifelike quality of the Xbox combat games approximate the environment they just left.  For many, this represents a “return” to their former lives, thus producing a sense of calm and reassurance.”

“I said that?!”  I exclaim, eyes wide.  “What kind of crap-pile hash was I smokin’ when I wrote that letter?”

“Oh, huh.  Um.  Well, if you didn’t notice…I wrote it.”  Says the assistant, looking dejected.

Short of tearing the letter out of his hands, and no doubt derailing an already fast-moving train with lots of passengers, I know I’m on the hook.

“Ok.  You win.  Xboxes all around!  On me.”

Relief, profusion, gagging urgency and more of that I-want-to-help-soldiers-but-won’t-listen-to-reason earnestness.  “Oh, THANK you!  Man, you have no idea what this will mean to the guys.”

“Can we just agree that you got me to sign yet another of those goofy Army things where you’re not really asking for medical opinion but if I sign the memo about 25 people will have busy stuff to do and somebody somewhere will get something to further the impression that they’re entitled to things that the average American pays for?”

“Um.  Sure.”

“Can we further agree that Xbox is not an accepted medical therapy for anything?

“Yep.”  Confidence growing…clearly the doctor is too weak to actually stop any administrative freight trains now.

“Fine.  You have your memo.”

He turns to leave.  Then turns back, “Oh, and about that memo for the massage chairs…”

But I don’t hear him.  I’ve crawled under my desk, looking for the Lost Thumbtack.  I don’t “find” the thing until I hear my door open and close.  Carefully I look up….he’s standing there, hand on the doorknob.  He’s smiling, one of those serious smiles that makes perfectly clear that nobody’s fooling anybody.  “Find your thumbtack?”

I sigh.  The sound is tired in my ears.  “Yes.  But I just tossed another one down there to go look for later.”  He doesn’t say anything.  “Yeah, the massage chairs.  Bring me the memo.  Until then, take this script-” I scribble onto a piece of paper.

He crossed the room and takes the script from my hand, smiling.

Massage Chair
1, bid.  Do not swallow.

 

RATIONal!

Yes, throwing a few words out there again.  Can’t help m’self.  Been a bit.

Living in Europe insulates the average human from goofy, over-the-top language meant to get people to do and think in ways that OTHER people want them to.  So, I haven’t been very caught up in, or all that impressed by, all the politics and steamy language coming out of my home country these past months.

Demilitarized Zone, North Korea

We have fast government. No arguing. You like. Like pizza.

Now the election is finally over, we find that Republicans have “swept” themselves into a level of “power” that assures exactly zero will happen unless they work with all the Democrats and Independents that never lost their jobs.  Some people think all the upcoming wrangling is a bad thing; I think it’s great.  A super-active government rarely doesn’t do anything well.  There IS a type of government that “gets things done” almost immediately, with little debate.  It’s called a dictatorship.  If you’re smitten with that idea, move to North Korea and try THAT speedy idea on and see how you like it.

Anyway, I received a link to a very persuasive and scary speech given by an orthopedic surgeon named Dr. David Janda, wherein he outlined the horrors and sneaky tricks piled into the Obama health care bill.  His speech was in support of Rob Steele, a cardiologist-turned-politician likely because he was mad as hell at the terrible direction of the country (*yawn*, aren’t we all?).  Presumably, said cardiologist is now back in the clinic, since he thoroughly

Republican Party Handbill, ca. 1880

Image by Cornell University Library via Flickr

lost the election of the 15th Congressional District of Michigan to John Dingell something like 83k votes to 118k votes.  Apparently, the Dingells have run that district for generations.  If you’re looking for nutty, inflammatory, manipulative language, look no further than at a political battle between a challenger losing in the polls as s/he tries to unseat a longstanding incumbent.

The gist of Dr. Janda’s speech is how Obama intends to RATION health care.  This actually sparked my interest.  I don’t really care about health care system politics; I’d rather just see patients, frankly.  But I have to just say to my fledgling SW101 crowd, I SUPPORT RATIONING.  Of every public resource.  Food. Gas. Sex (um, although I’d readily opt out of the “public” option).

New Orleans, Louisiana, 1943. Line at Rationin...

The whole idea of capitalism is so you don't have to share. Sharing sucks.

So many people take the idea of rationing to be unequivocally bad…as if it’s totally wrong and even beyond debate.  That’s the tack of Dr. Janda.  It’s something we all KNOW is wrong.  Like sticking needles in the eyes of baby squirrels or stomping on halloween pumpkins.

Incidentally, Janda is a specialist, supporting another specialist.  Primary care docs like me aren’t especially pleased with how specialists have garnered power and money for themselves in the AMS (Am. Med. System).  In particular, I’m speaking of orthopedic surgeons and cardiologists.  Specialists make fabulous money by ordering tests and procedures, none of which have ever been regulated or rationed in any way.  Echo’s and caths pay for the boat, private school and vacations to S. Pacific islands nobody can name.  Don’t tell me the only force driving clinical decisions is scientific evidence and standards of clinical care…money is money.  But even so, I’m for rationing.

President Barack Obama speaks to a joint sessi...

Hey friends! Here's a really mediocre idea!!

Let me say that I’m not happy about Obamacare. It was said well @ a recent conference, “who’s going to do a better job coming up with a fair, affordable national health care plan, 189 laywers in a room for half a year, or 10 family doctors in a room for a week? Obama went with the lawyers, he should have gone with the docs.”

That said, I FULLY AND COMPLETELY agree with rationing because it’s a necessity. In training, I followed a patient in the ICU who was costing close to 1 million dollars a day of PUBLIC MONEY for the last 4 months of her life. Somebody, somewhere needed to compassionately deny further intensive care to this woman, instead providing dignified hospice end-of-life management. Her case justified ONLY taxpayer-funded hospice care but nobody had the cajones to tell her that.

Every precious resource, if pooled for the common good, needs to be rationed. It’s where we get the term ‘rational’ and there’s a reason for it. Closer to home, my sister apparently has a University doctor telling her that she needs a thousand dollar procedure (colonoscopy). The procedure is not done by this doc’s specialty, and my sister hasn’t even had a rudimentary work-up to justify the cost of the scope.  She has not had a professional analyze of the risks vs. the benefits of doing it, either.  Yet she’s already being told that she needs this procedure.

Remember…EVERY test and procedure has significant risk associated with it. Wouldn’t it be nice to know that the doc my sis sees for a scope is a specialist? And, since that specialist pays for the Benz and sailboat from scope income, wouldn’t it be nice to know that he moved in a stepwise fashion through the GI workup process, a process that is peer-reviewed and widely accepted as essential before a scope is ordered?  This is the ‘rationing’ process that Obamacare advocates.  It puts serious limits on specialists in the provision of their care when it comes to big-ticket stuff like scopes, imaging and surgery.

But remember, we’re talking about rules in effect ONLY if you intend to get your neighbor to pay for your health care. YOU are welcome to pay for your own scope any time you wish. YOU can fund your own health insurance – one that doesn’t make docs do ANYTHING before they dig into your body – if you want.  I watched it work this way in Israel, and it was a pretty good deal.

However, the fact is most Americans believe they are SO important that they have the right to be treated like kings…paid for by peasants. But ethically, Americans have no right to whatever care they want whenever they want it, if they also expect someone else to pay for it.

Hugh Owen Thomas (1834-1891), British orthoped...

Trust me, I'm a DOCTOR! We ALL are.

The AMS does too many procedures and tests. The result of both is astronomical costs and HARM TO PATIENTS (through false-positive test results and procedure errors). So, not only is care rationing ethical and less costly, it is absolutely safer for patients. Healthcare is NOT safe. There is a risk-benefit ratio that must be considered any time a patient comes in contact with the health care system. Waiting for non-urgent care (knee replacements) and rationing of tests and procedures is ethical, cheaper and flat-out safer.

Incidentally, I argued this point in a debate in med school…waay before Obamacare. I have seen nothing since that time to sway my opinion. In fact, training and practice have only solidified that opinion with real-world facts.

Obama didn’t make our health care system right, but he did make it better. The Tea Party idea of repealing the new law is lunacy. If they REALLY want a free-market system, they need to dispense with EMTALA laws which dictate that ER docs (and now other specialties too) are required to see any and every patient.  THIS IS UNIVERSAL HEALTH CARE!!  It’s just the most inefficient, ineffective and expensive system in the world. We do have a social healthcare system. We just need to make it rational…starting with sensible rationing of limited resources.

Movie Review – Avatar

I enjoyed myself fully last night as I entered the world of ‘Avatar’, James Cameron’s new sci-fi epic that already handily broke a 1 billion-dollar landmark record of some kind.  I’d watch the show again tonight if I could.  I’d probably watch it every night for a week like my high school buddies did for “Bill and Ted’s Excellent Adventure” once upon a time.

You don’t have to care – or understand – the point of the movie to completely enjoy the stunning visual spectacle presented in wide-screen, 3D wonder.  In fact, I’d advise constraining yourself specifically to the visual effects and skip putting any real thought to the message of the movie.  In essence, just sing along with the song, but don’t think about what the words actually mean.

The story follows an ex-Marine named Jake as he becomes part of a mission to subjugate – or at least translocate – the natives on a strange new planet (a moon actually, but does it matter?).  On the n0t-so-subtly-named Pandora, the “aliens” congregate around an enormous tree set in the middle of a seemingly endless forest.  They stand about 11 feet tall, with blue skin and luminous yellow eyes and they all seem to carry bow and arrows and daggers.  These blue and tall but otherwise disappointingly human-shaped beings generally seem happiest when attending their frequent tribe-wide drum fests – with a terminally simplistic 2/4 beat rhythm that sounds like it might have been pounded out on cool Senegalese drums the Anglo orchestra bought in bulk.

These earthy aliens have a sacred, mystical, spiritual connection to the forest where they live; generally behaving like any nature-loving tribe the Europeans successfully decimated a little over a century ago in North America.  In a complete creative hiatus, at one point nature is even called a “mother”.  Why not a father, or brother, or just skip the nuclear family reference to nature entirely?  The descriptor ‘Mother Earth’ is so unoriginal, it ranks up there with Bless You and Dot Com.

Although 2 hours and something like 40 minutes, you can easily sum up the movie in one phrase: “Dances With Wolves”…but with pterodactyls you can ride.

Basically – Marine makes contact with natives through project financed by aggressive and ethics-challenged Big Business company.  Marine plans on helping his financiers destroy said natives.  Instead, he inadvertently falls in love with natives in general, and one curvaceous native in particular.  He then becomes the enemy of his former bosses, ultimately leading the meek, dumb, dark-skinned simpletons to victory over superior white man.

I haven’t decided if this REALLY tired theme of the White Male swooping down into a primitive race, seeing their genuine good, and then becoming their Great Savior is completely racist.  Some are saying it absolutely is.  I don’t really think that was the intent.  I just think it was lazy writing by a white male who deep-down believes that white men are still the best hope for the world.  That they still run it, ultimately.  But it is possible that white men really don’t have much to offer the world anymore – that we’ve had our time and made our mark.  Maybe it’s time for some non-white, non-men to run the countries, write the laws, own the companies and save fictional worlds.  Maybe the white boy has done about all he can.

Big Business takes a major hit in this movie.  It gets portrayed as the denizen of all Evil in life.  That said, it’s Big Business that has paid for every iota of scientific discovery that has occurred on Pandora.  The science taking place on this moon (and taking place on our earth) is an elevated form of existence, no question, but in both worlds it mostly exists because of Big Business, either directly or through taxes.  Scientists – and artists – need to accept the fact that to live in that enlightened world of thought and wonder and possibility depends on their benefactor’s mundane ability to sell widgets.  Big Business is rarely genuinely evil.  True, figuring out when to inject some profit-endangering humanistic principles into a business plan does takes some skill and is occasionally gotten wrong. But for the most part, if business didn’t make the poet, at least it feeds him.

The actual “avatar” is a living being made to look like the aliens, but controlled by the mind of a human.  The human links to the avatar neurologically, so it can only be controlled by one specific human.  Thus, the human lies in a coffin-like body-pod that connects him/her to their specific avatar.  Upon falling into a coma in the pod, the avatar wakes up and the mind of the comatose human controls it.

Soohh...who gets to clean this thing?

The doc in me couldn’t help but get hung up on this part of the movie.  First, all humans need to sleep.  But since the avatar wakes up as soon as the human “sleeps”, and since controlling the avatar is a conscious process, the human never actually does sleep.  For some evolutionary reason I can’t fathom, REM sleep is the foundation of all life.  This inconvenient fact defies even the mighty pen of James Cameron.  By the end of the movie, after staying awake vicariously with the characters, I felt like I’d been on call in the hospital for days on end (felt like I was back in residency again).

Also, the human lays in this coffin thing for hours and hours.  At the least, he’s gotta pee himself on a regular basis, to say nothing of the inevitable bowel movement here and there.  Plus, the main character’s avatar hooks up with the sexy female alien.  Depicted as the first consummating night of an eternal love bond – thus likely a multicoital affair – envisioning the scene (and smell) inside the pod after this particular night left me a bit squeamish.

As mentioned, the power of this movie is in the visuals.  It is a “looker” many times over.  But the general message is tired, probably slightly racist, and denigrates the U.S. Military (or at least leads the audience to exult in the widespread slaughter of American soldiers/mercenaries).  That said, perhaps our culture really should take the main theme of the story to heart.  After all, we DID decimate the Native American culture, and based on my experiences on the Crow Reservation in Montana, I’d say we continue to.  We’re also strikingly obtuse in our dealings with tribal cultures in the Middle East today.  Listening to people from a different culture – rather than melting them with daisycutters and circling drones – has some merit.

But I do wish the movie had added a little post-modernism into the mix and eschewed the evil-good idea altogether.  It didn’t have to pit the American Axis of Evil (big business + U.S. Army) against a pristine tribal culture practically perfect in every way.  Historic Native American tribes were often duplicitous, aggressive, thieving and hateful (many still are today).  They rarely trusted each other from tribe to tribe and may have been just as irresponsible had one tribe attained the raw power that the U.S. Government currently has.  The Arab tribes we’re tangling with recently have a litany of faults and cobwebby dark corners too.  But they are also a just, priceless, sacred, honorable people.  This dichotomy exists in virtually every race in our world.  Americans seem to hate this complexity in our fiction – it’s easier to hate one thing and love another and then watch them duke it out.

Yeah, YEAH! Die lame-oh Americans! Wait, didn't an American make this movie?

Thus, the conflict in the movie could have been between two parties filled with faults and frailties but ultimately imbued with genuine honor, honesty and a respect for the rights of others.  Standing between them is something they both deeply need and want (trees, mineral ore…whatever).  In life, conflicts almost always boil down to two parties who both have blood on their hands, but both are essentially good, honorable…and in the right.  e.g., Palestine wants the land, Israel wants the land, both have been evil at times, both have been angelically good at times, and each have some form of legitimate claim to the exact space of real estate.  Stick that conundrum in your avatar’s virtual peace pipe and take a deep drag, nature-brother.

Depicting this nuanced world may have weakened the sense of righteous rage as the Army went Operation Flatten Everything.  It may have lessened the gloating release when the Ultimate Bad Guy finally met his ignominious end.  But it would have made a better movie.  It would have made the written story as complex as those fantastic visuals, and created a worthy counterpart to such a sparkling, wondrous vision.

The Toilet Excuse? Really?

“I need more drugs because I had a heart attack yesterday and in my monumental pain I flushed my Percocet down the toilet.”

I stare.

 

AWwww, MAN, I don't know WHAT happened, man.

“No really.  I’m serious.  I don’t know what’s going on with my heart and I accidentally flushed my drugs down the toilet when it was causing me, like, serious pain.  I REALLY need some more.  I’m in like 24/10 pain.”

 

“That’s a pretty strange fraction.”

“Well, that’s how bad it is.”

I hope my eyes are at least a little more than half-closed, “Dude.  That’s your excuse?  Really?  That’s the best you have for me?  Flushed?”  My ever-blindingly cheerful mood deflates a bit.

“Well, it was the case manager who told me to come to you for more Percocet.  I tode her Dr. SW101 isn’t cool with narcs, so I figured you wouldn’t go for it, but she told me to try.”

“So, the NURSE made you do it?”

“No…well (looks hopefully at me), uh, maybe?”

 

Dr. SW101 set me UP!

He did utter one truth, I’m not cool with writing for unfathomable doses of highly-addictive, mind-altering substances that have outrageous street value and regularly cause the utter destruction of families, careers and lives.

 

He’s right.  I’m not cool with that.

Sometimes it feels like I’m just sitting in my clinic handing out bullets…each one stamped with “If this causes a disaster of any kind, please blame Dr. SW101.  His bank account number is 7749220485, and you can find his children at 13 XX street, usually after 6pm.  Punish him accordingly for making such a mockery of his Doctor’s Oath, society, God, the memory of Elvis, Stonehenge, Hello Kitty, Gooeyducks..and everything else even remotely sacred to humanity.”

But I’m used to that.  I’m used to being the candy man.  What I’m NOT used to, is being taken for so dimwitted that the medical equivalent of ‘the dog ate my homework’ excuse might work on me.

“You’re really using THAT one on me?”

“Look man,” (whips out his Blackberry Smartphone, provided free of charge by the Army to help with his healing), “I got pictures of the pills in the toilet.”

I decline the visual.  Don’t even need it.

“You’d need to pin my face to a cork-board with something in the range of 34,000 thumbtacks to talk me into giving you more narcotics with that lame excuse.”  I say.  What I DON’T say is that aside from fighting the good fight against blatant drug addicts (I do take care of true heroes; he’s not one of them), I’m just flat-out annoyed at the excuse.

“Frankly, you’re story is miserable.  Put in a little work, and you might score a few hits out of me for creativity.  I’ve been known to drop a few Vikes on someone just to tribute their impeccible style alone.”

“Style?”

“Yeah, you know, do some deep-thinking before you try get me to double your daily horse-halting, blue whale-euthanizing, brontosaurus-stupefying doses of addictive opiates.”

“Liiike, a better story?”

“Yep.  I loovvve fiction.”

“Um, like what?”

“The doc I’m replacing was partial to “I washed ‘em in my uniform”, so I’d say that’s a little, uh faded haha no pun intended *aHEM*, sorry, not making light of your “pain” or whatever, just a little side-joke for this glorious Army morning.  Anyway, where was I?”

“You were helping me come up with a story to score more narcs out of you.”

“Oh YEAH.  Thanks!  Let’s see, maybe I can help you….next time, try something along the lines of:

 

They're real. Seriously.

After a valiant but ultimately tragic battle, a saber-tooth tiger ripped your friend’s head off.  In desperation, you heroically dispatched said wildcat with your bare hands (careful with the back).  Then, without pausing to consider yourself, you gave him your ENTIRE BOTTLE of pills strong enough to drive the entire population of Gambia into rehab.

 

Unfortunately, when he swallowed them – since his head was removed from his body – your pills just dropped out on the ground, all slimy and spit-covered and quickly dissolved.  Thinking fastly, you propped his body up and then held his head over what you figured was the esophagus part of  your life-long friend’s neck so the remaining few pills – “Damn you, Johnny, swallow! – dropped out and settled into one of his neck-tubes, hopefully not the trachea.  Then you got him to a local ER, where they skillfully re-attached his head.

ONLY THEN, after your friend was recovering (he just might pull through, snif), did you think of yourself, realizing that you were, in fact, out of drugs for your endless back pain and heart attacks which you’ve been suffering from since you were born, 20 years ago.”

That would work?”

“No.  But honestly, that story has more credibility than, ‘I flushed ‘em, brah, gimme some more.”

Numb and Numb-er

I’m happy to announce that I now drive a Mercedes-Benz.  It’s true.  A real in-the-steel-and-glass Mercedes.  The model is a C-180, which is the 4-cylinder, 4-door model.  The smallest engine they make (great gas mileage).  To boot – it’s green, my favorite color.

I’m a doctor now, people.  Apparently helping sick people entitles me to the high-life.

Truth is, here in Germany, the term “hooptie” is a known, legitimate noun.  The term is used to describe nice German cars that are (usually) bought by Americans and then run into the ground.  You can pick up BMW and Mercedes hoopties for 500 euros.

 

merced

Mine looks just like this one...but way cooler.

My car isn’t exactly a hooptie.  In the States, it would probably have cost at least $5,000, maybe more.  I don’t really know because I’ve never been in the market for Mercedes-es.  But I got mine here for a few thousand bucks.  It’s still in good shape and as long as I take care of it (an expensive proposition in Germany), it should get me around for at least a few years.

That is…unless it takes a few years until my new monument to affluent living is allowed to take me anywhere.

Take the Army’s torrid and longstanding love affair with bureaucracy and combine it with 1000 years of rulership of the masses in Europe, you get the process I dealt with just to be allowed to drive a car.

Buying the car is easy.  But in this Germo-Americo Funkenthink, the quagmire starts there.  You first need a special driver’s license, which requires a half-day class and then a 130 question test ( which I immediately failed by about 15 questions).

You also have to have insurance on a car before you actually register it.  And, the car needs to be inspected.  But you can’t drive it to the inspector’s unless you have it registered and insured.  But if you fail the inspection, you’ve just registered and insured a car that sucks.  So, you have to de-register it (I did that – twice – before I settled on the Mercedes).  De-registering requires a trip to the local customs office (American) plus a second trip to the other customs office (German, 35 min drive), numerous forms, money, waiting and…all the while you still need the insurance.

So, I’ve been a little reticent to drive much unless I have to.  I’m always wondering if I actually have all the paperwork and proof that will allow me to stay out of jail were I to get pulled over.

Instead, I came up with an alternative (heh, heh):

Through some highly unfortunate events in my brother’s life, I ended up with his Harley motorcycle.  Now, make no mistake – I owe him for this very expensive bike.  It was a ‘take-care-of-my-hoss-for-awhile’  kind of proposition.  Of course, being a deeply loyal brother, I immediately agreed to “help out”.  But, not being a big Harley-lover, I…well, I sold it.  And I bought a BMW motorcycle instead.  Initially, I sold it to help fund out trip out here, and a portion of the Harley money was a HUGE help in getting us here.  That said, I GUESS whatever money we had left over should have been sent back to my saintly bro.  But with all these fantastic German road machines around, you sorta just get Beemer Fever.  What was I supposed to do?

And anyway, my bro is about 10,000 miles from me.  Is he really going to come get me when he realizes I sold his Harley?  I mean, c’mon, I did the guy a favor!  BMW vs. Harley is a no-brainer.

 

bmw

Mine's just a LITTLE less shiny and has panniers.

So I now fly along the German Autobahn on a R1150 RS BMW.  Riding a bike like that, in this part of the world (any part of the world if you worship BMW bikes) is an experience that is hard to replicate.  Harder to describe.  At 80 miles an hour, I blow by stunning autumn trees, taking in their blurred resplendence in shimmering hues of gold and yellow and red.  “My” bike purrs along effortlessly.  When I lean over the gas tank and duck behind the faring, the engine sounds something like a sewing machine, but even softer, maybe more like two feathers rubbing together.

There’s only one problem…Germany is COLD.  The other day I left for work in the dark, road sparkling with frost, at a temp of -2.5 Celsius.  Buh-rrr.  And this is only OCTOBER.

The night before, I had received a notification in the mail that my car did not have the correct license plates due to a dating error in the – you guessed it – insurance policy.  So, should I be pulled over in my esteemed Mercedes for any reason, I could expect to be hog-tied, whipped and sent back to the States crisply folded into a shoe box.

Thus, while my longsuffering wife dealt with the paper-pushers in Hiedelburg, I rode the bike to work, frost and chill notwithstanding.  I do have some decent riding gear I picked up when I first got the Harley.  I have a jacket with armor in the shoulders and arms, and pants with knee and hip pads.  I have big thick gloves – also a “gift” *ahem* from my bro – and good riding boots.  All the gear is made to withstand serious wind and rain.

 

jeff_daniels1

"Got a little nippy back there going through the pass, eh Har?"

But I’m not sure any gear will hold up for long when receiving a direct 80 MPH sub-freezing air blast for 40 straight minutes.  Mine didn’t.  By the time I got to work, I was so cold most of joints wouldn’t bend.  I walked into the clinic like I was in a body-cast.  I don’t think I even spoke to my first 3 patients that day because I couldn’t unclench my jaw.  I just nodded compassionately with my hands buried in my armpits and gave ‘em whatever drugs they wanted.

I probably should have just sold the Harley and given whatever money we didn’t need back to my brother.  But instead I chose to buy a Beemer with the extra cash and freeze my face off in Germany.  If you love BMW motorcycles, you’ll understand completely.  You’ll probably applaud me for such a wise and intelligent idea.

I’m cheering, anyway.

Ode To Mr. Fingerprint

We can’t figure it out, exactly.  There isn’t one thing that we can point to and say, “Yeah!  That’s were everything became too much.”

But somewhere along the way, this little adventure piled up and reduced both of us to tears.  How the Army manages to organize itself enough to go around the world killing people – unless through excessive paperwork – still mystifies me.  But I can say that if they just stuck to the paperwork – threatened to attack the terrorists with administrative paperwork – world peace would be ho-hum news. 

“We give up!  We recant!  Never mind all that Allah stuff!  We’re Americans now.  Look, look, we’re buying Hummers and we all have flat-screen T.V. in our camel-skin tents with only CNN and Disney channels on them.”

I will say this:  With exception of the laudable fingerprint dude, I have never been to an Army office and gotten done what I came there to do on my first attempt.  Never.  And, for the guy to do my fingerprints that day, he had to overlook 2 reasons to send me away. 

If I’d had a trophy, I would have given it to him.  I DID sing his praises; describing his feat in a halting, emotional, too-grateful voice.

“I….I….I just want to let you know that.  *AHEM!*  Sorry, something in my throat.  Some sort of lump.  Anyway….”

Corpulent man in too-short square tie knit by kids in Taiwan R.O.C. funded by Wal-Mart stares dully, shifting slightly in his creaking office chair.

“You’re the first, EVER, to give me what I came to get on my very first attempt!  It’s a record.  Over the past 6 months, in dozens – maybe hundreds – of office visits my wife and I have needed to make just so I can do a job, you’re the first to not send me away on my first request.”

“Huh.  That’s good.  Fill out an I.C.E. card, alright?”

“What’s that?”

“A card.  You know, a card.  Tell ‘em how I’m doin’.  Let ‘em know I set you up.”

Right.  I.C.E. card.  I took that thing home, spent 45 minutes filling it up with love and gratitude toward the first man EVER to spare me making 2+ trips just to get a simple administrative task done.

Then I realized it would take another trip to that office to put the card in the guy’s box.

And I shredded the thing.

What Price, Integrity?

2000 Euro, apparently.

Through a housing allowance loophole, I could have almost certainly been approved for an extra 1000 Euro per month for the next 2 months.  The arrangement would have been a classic “kick-back” scenario between me and the owner of the house we’re buying.

However, in a last-second surge of some strange amalgamated emotion at least distantly related to those of guilt, honesty, obligation and craven fear, I killed the deal.

We are, in fact, buying this house, but will rent it for 2 months until the financing officially comes through.  During this time, my housing allowance will cover the rent – nothing more.

Quite honestly (since we’re on this honest kick), I feel sick about it.  I feel like I walked by $3,000 cash in a bush, and left it there.  I also feel it was the right thing to do.  But believe me, I had all the paperwork set up to take advantage of the oversight up until the final hour.

I should mention that the stakes are high right now.  The move to Europe is turning out to be much more stressful than I imagined.  This place is UNBELIEVABLY expensive.  I don’t understand how anyone can afford to even breathe out here.  I need to get my family out of debt…not go further into it by moving out here.

Let me quickly describe a government “housing allowance” as it pertains to me.  Termed the “LQA” or Living Quarters Allowance, anyone approved to live “off base” (most of us civilians are) is put on a scaled allowance.  You get more money for your status on the hiring scale (I’m waaay up there), and your number of “dependents” (pretty thin air on that one too).

So, when initially told of my housing allowance, I rejoiced!  I’m allowed thousands of dollars a month to spend on housing and utilities.  What a sweet deal!  In deciding if I could afford to take this job, I added my allowance ceiling (close to 50,000 per year!) into my yearly salary.

Keep in mind that my government pay as a doctor is very low in comparison to my private colleagues.  But when I added my LQA – viola! – my salary magically became competitive with the rest of the new-entry family docs in the country.

Then I arrive here to find that, essentially, it’s impossible to spend my LQA.  The arrangement is a “use it or lose it” kind of thing.  If you only spend half of your allowance, you can’t have the rest in cash.

The allowance, really, is a virtual amount that allows me to live pretty much wherever I want during the time that I’m here.  But even the nicest places in the area don’t rent for anywhere near what I’m approved for.  It’s like being told that you just won 1 BILLION DOLLARS!  Buuut, you can only use the money on M&M’s, and they can only be eaten, not sold.  Effectively, I’ve been given a lifetime supply of all-I-can-eat M&M’s.

I can’t have the cash, and, as you might imagine, I also can’t go to a landlord and say, “You’re charging 1100 euros a month for rent.  I’m approved for 3000.  How ’bout you and me split the difference every month?”  A housing office has to approve the rent amount based on an inspection of the house, and it won’t pay above that amount.

This thinking is classic for government, where everything is about sustenance.  Nobody is supposed to capitalize on government money.  You can only be sustained by it.  If you’re important, you can be sustained in really nice conditions.  If you’re not important – crappy conditions.  But either way, you aren’t to actually make money.  It’s unapologetic communism.

Getting kickbacks from your landlord is considered unethical.  And, effectively, this is what I had the ability to do for the two months until we buy our house.  As mentioned, I didn’t go that route.  I feel sick about it.  Not noble.  Not honest.  Not righteous.  NOT cool.  And pretty dumb.

Here’s a few reasons I pondered to justify the choice:

-The unethical thing is that doctors are paid so little in government work. They should have a program that either pays salaries commensurate with the private sector, or add an actual and functional loan repayment component to the salary (most current guv repayment programs are worthless – at best – and complete deception at their worst).  I really, truly, don’t care about money.  But the debt I carry sickens me.  I’m left to fend for myself on their paltry salary and a lifetime supply of M&M’s.

-I was deceived about the LQA.  Sure, it wasn’t deliberate…probably.  All the details and stipulations were simply left out.  But I came out here thinking my salary was 50k better than reality, when it’s really only about 15k.  Yeah, it’s cool to pick virtually any place I want to live.  But not really.  I’m chained to my debt.  And those chains are pretty heavy…too heavy to allow for much swimming in my rented pool in my rented German villa.  I need to make financial choices that will free me and my wide-eyed children from this financial prison.  The system should allow for that and it doesn’t.  I need to exploit loopholes wherever I find them.

-Also as a wealth-building strategy that I would HAPPILY forgo were I debt-free, we are choosing to buy this house. This puts added pressure on me to be happy in my job, and to stay in Europe for 5-10 years, rather than my stipulated 3.  If I want to leave, owning a house highly complicates my exit strategy.

-My mortgage is nearly $600/month more than the housing office has approved for the house in its current condition. So, if I want to rent the house to someone, I can only charge the max amount approved by the Housing Office.

However, the house has an extra bedroom that was not counted during the last inspection because it needs renovation.  We could pour 2000 extra Euro into renovating that bedroom and adding a bathroom next to it.  This would increase the allowed amount I can charge to a renter. I’ll bet the house would get approved to an amount very close to my mortgage with some good renovation.  Then, I can go to work every day in the freedom that if I get fired, or if funding for my slot dries up, or if I hate the job and want to go home…I can rent the house out without going broke (houses don’t sell well in Germany…sometimes sitting on the market for years, but the rental market is hot because of the military activity).

-I won’t get caught. People do this kind of thing all the time.

-I’m only using what I’m approved for. Not more.

-The Realtor did it. I didn’t think this up.

-Maybe it’s ok in my case, since the loophole doesn’t exist for most others (my rental contract doesn’t need approval from the housing office).

Reasons Against:

-My Dad’s face in my mind: The guy works every day.  Supported me every day since he adopted me.  And pays taxes, every day.  He got behind on taxes once, and getting square with the IRS nearly killed him.  But he did it.  Little by little, he gave them every dime they demanded of him.  My housing allowance is paid for by guys like him.  I’m not ripping off millionaire Senators with health care for life…I’m ripping off honest, real Americans who believe that their taxes are being used appropriately.

-Professionalism: Frankly, many of my generation’s colleagues, myself included, hate this word.  What once was a sterling understanding between every member of my profession has become an strategically ill-defined mechanism for manipulation, money-making and power-plays by Boomer Gen on Gen X/Y.  Happens all the time in residency, but banks play the game, insurance companies, lawyers too.

Still, a fundamental element of professionalism is a high standard of honesty.  We say what we mean, we mean what we say, we stand by our word and play it straight.  Doctors regard trust as immutable currency in the most sacred component of our profession, the doctor-patient relationship.  This is the very fabric of our livelihood, and it all is built on trust.

-My training: Let me be discreet here in saying that during residency, I had a few moments where I was *ahem* mildly cavalier regarding my whereabouts on certain mornings.  This lackadaisical approach to the exact truth led to some harsh responses from those who oversaw me.  I got my ducks in a row pretty quickly.  Now, the stringently honest approach is the only one that feels right.

-Sleeping well: Also a lesson learned in residency: if you didn’t do anything wrong, you don’t have to worry about getting caught.  In the movie, “The Hunt for Red October”, a submarine captain prepares to fire torpedoes at an enemy ship…but first he puts a safety on them so that they can’t explode until they have been swimming around for awhile.  “I don’t want those fish comin’ back on us!”  He says.

For me, the same thing is true.  I don’t know – really – how closely they’re watching what I do.  Maybe this is a big problem right now.  Maybe they’re working on closing the loophole and will be auditing everything once they get the new policy in place.  Maybe, maybe, maybe.  I can go to sleep tonight not worrying about the maybes.  I played by the rules.  If something is messed up, I know it’s an honest mistake – that I’m not “busted”.  Makes for an easier thought life (allows me to wring my hands about foreclosure without any messy distractions).

So there you have it, folks.  The emotional undulations I’ve endured over this weekend, mulling the ethical conundrum over and over in my mind.  I feel sick about it.  Improving the house doesn’t just help our investment.  It gives me freedom in my job, freedom to enjoy Europe, freedom from worry.  The pill has been a bitter one.

My brother told me recently that now, as a doctor, I’m not really going to care about a few thousand bucks here and there.  Sure, I’ll be careful with my money, but a few grand won’t be something I’ll break my back for like I would have in the past.

I hope he’s right.  Because that 3000 bucks sure feels like a lot of money at the moment.  I’d work pretty hard for those extra thousands right now because of how much they could help us.  But apparently, I won’t lie for them.  One day, finally out of debt, I suppose I’ll look on this choice as a good one.

For now, I regret it….although I am looking forward to a good night’s sleep.

Favorite Quote of the Healthcare Debate

“The Government should stop trying to run ‘Death Panels’ to decide who gets what care.  This is terribly wrong.  Death Panels should be run by insurance companies, just like they always have been…”

The Daily Show