From John Seidenfeld:

Harms way

I wanted to leave you with something I am passionate about


Table of Contents

Harms way 1

I wanted to leave you with something I am passionate about 1

The Medical Library, December 2050 4

Mr. A 6

Dr. Middleman 13

Letters to the editor 19

Mrs. A 19

The Medical Society Response 20

Cook County Hospital Association 21

Excellence in Medical Care or EMC 22

Letters from beyond; imaginary conversations Mr. and Mrs. A had after his death recorded by Mrs. A 24

Dr. W. and five tenets of care 28

Truth to Power; “Getting and spending we lay waste our powers” … W. Shakespeare 31

Legitimacy of snake oil 40

Asses and Elbows 45

The Reactive Cook 46

Don Quixote 48

Tangled strings 50

Five percent of all medical knowledge 56

Mona Lisa 59

Mr. B. 2048 60

Artist P and Nine lifetimes 67

Yuan 69

Center of excellence and value 71

Mother of Medicine 75

Wrong account 78

Re work and wrong directions 80

Hunger distracts again 82

The Campaign for President of the U.S.A. 2008 84

Millennium Park 87

Do Angels watch us and listen to us?  Rights and rites 89

Generational outreach 93

The concordance of factors 96

Union Station 98

Index 100



The Medical Library, December 2050


"I am sorry you are unable to cure my cancer."  With these few words beloved Great Grandmother cast a shadow of shame, sorrow, and guilt over the author, a fledgling student of medicine.  I have been passionately trying to learn more about medical science and practice since that day.  For this reason and many others your humble historian sits on a comfortable couch in a Chicago medical library surrounded by old documents, leather chairs, and countless bound volumes.  Voices of ancestors and mentors fill the air, and tell stories of a time long ago.  My life is now devoted to the study of medical history.  In studying the history of medicine, the author communes with present practitioners and those long past.  How did we get to the situation of the current day?  Is health care today the result of small steady changes or an infusion of brilliance, an alien hyper-leap?  The sequence of events that has led us here is amazing.  We might have been living in a post-apocalyptic Earth if we had not avoided nuclear holocaust.  That vision would hold no room for quiet and contemplative study, and most of medicine would be inconsequential.  Fortunately, the country is into another century, at relative peace, and the pace of degradation and demolition have slowed.  The wisdom of our founding fathers and mothers is an ever-present gift open for exploration.

            Great fortune has blessed this endeavor.  Since so much of late twentieth and early twenty first century medical practice was documented on paper, much information is available.  Privacy of records is a prime concern.  Confidentiality agreements have been signed which allow me to carefully and prudently use the information available.  I have pledged to protect the identity of those whose confidential information was recorded.  Examples used in this text are not unique, and should be seen as generalizations of care long past.  Public information abounds and is documented.

            When the yellowed pages are opened (so fragile that many would break when handled if not preserved) it is amazing to see how far we have come.  I prefer to hold the records in my hands rather than view scanned computer images.  The channel between hand and brain is open whether I am reading the written word or writing it.  Hands holding the records link with past writers, patients, and clinicians.  The author’s background is classical training in allopathic and osteopathic medicine.  I cared for adults with medical problems for forty years, and during that time also went on to study history receiving an advanced degree in this discipline as well.  The current work is a documentary hologram describing the transition in medical practice over the past one hundred years starting in 1950 AD.  As we approach the year 2050 AD many programs are scheduled to remember our past.  In the text that follows, late twentieth, and early twenty-first century medical care are discussed.

            The reader is cautioned to suspend disbelief and judgments.  It is common to disbelieve the past. There are those who do not believe the Holocaust occurred, and probably some who think there is no Grand Canyon.  Instead bring appreciation, interest, and creativity to mind, and be grateful for our current state.  Is it possible that our predecessors worked in a primitive process without evidence to support their practice?  Was quality of care a metric available to clients of the health care systems?  Were practitioners and systems trusted or were ulterior motives suspected?  Why did most people trust them with such important life decisions?  What impaired their progress in improving care and care delivery?  Why would intelligent beings not overcome the inertia of their time when so much was at stake?  Is it possible that they toiled in the way of eighteenth century cottage industries despite the changes in process improvement that occurred in fields such as banking, law, and manufacture?  Why did their vital statistics lag so far behind the rest of the world despite their advanced and advancing technology?  Did they really believe they delivered the best care in the world despite poor rankings in childhood mortality well below thirty-seven other nations?  How were racial disparities in care and vital statistics accepted in a democratic society?  Why was care withheld from the poor?  In this research, 600 records from patients with complications of common therapy for heart disease were reviewed.  A complete analysis has previously been published in the Annals of Internal Medicine, and in it is detailed conditions, complications, health care system weaknesses, comparisons between previous systems and that of the present in terms of outcomes, ethical dilemmas, and costs of care comparisons.  The case presented here is the median case, and represents a significant group of people who suffered as a result of an expensive average health care system taken in Toto.  For a more complete discussion please refer to the above mentioned article.

Mr. A

The first record, 20061130A. (this record is on paper, hand written with ink); It is rendered it in the past tense for the reader, but otherwise left it intact.  It documents care in the year 1999, and is similar to many read during this research.  It is about a man who was brought into an emergency care facility located in a major metropolitan area.


Chief concern

Chest pain


History of present illness

Mr. A. had been at home with his family.  He and his wife had discussed his stressful work situation.  Over the past few weeks he had felt pains in his chest that were vague and short lasting.  His wife brought him antacid tablets without relief.  He tried to ignore the pains in hopes that they would go away.  The last few days the pains lasted longer and were more frequent, and tonight the pain would not stop.  He described the pain as a tightness in his left chest, and also felt pain in his neck and left arm.  He no longer dismissed the pain as muscular strain.  He felt some nausea and a slight fever as well.  He was exhausted and extremely weak.  He had never before had problems like this but he was reminded that his mother died of a heart attack in her seventies.  His blood pressure was high and poorly controlled as he often forgot to take his medicines.  He was overweight and had been told to watch his “sugar”.  He had smoked more than one package of cigarettes per day since teenage years.


Past Medical History

Medications-he did not remember the blood pressure medicines and had not refilled them because of cost and lack of effect (though he did not know his pressure numbers).

Allergies-none known


Injuries- “bad knees”

Lifestyle-smoked and overate regularly, and did not exercise. 



Social History

Mr. A. was a fifty-six-year-old accountant with many concerns and much suffering.  He had been married to Mrs. A for thirty-three “wonderful” years as he might say to friends (after the second glass of wine).   The couple had three children, all gifted and bright, and all teenagers at the time of this record. College and the costs of college educations were concerns for Mr. A. as he wanted to give his children the same start in life that he had.  Just thinking these thoughts brought a vision of A.’s father to mind; his father would say that the greatest investment he had ever made was in the education of his children.


Work was not going well for Mr. A..  He worked in a large fortune 50 corporation.  He witnessed jobs going overseas, going to younger associates, and “lost” in re-organizations and “synergies” of mergers.  The next merger might be his last as the company tried to “right-size”.  For this reason, he had visited with friends who work in the city, and explored what the market for his skills might be.  “Never hurts to look” became his mantra.  The job stability of days gone by was a fond memory for some, but A. had come to look at work retention as a cake walk.  Some would be standing when the music stopped, and would leave the game to others.  Skills were important, relationships with co-workers were important, but sometimes no chairs were left, and it was time to leave.  A. was grateful for his time, and appreciative of years gone by.  Still it would hurt to leave, and those who had preceded him out the door showed considerable disappointment and sadness.  He had tried in his way to make improvements, and help the company through its mission and values.  In his mind he heard “one may lose many times but try again to better your performance; losers are those who quit trying” and “if you never swing, you never hit the ball”.  He wished his mind would talk to him less. *


*editor’s note (this note must have been written by an intern or student as 20th century physicians were much too busy to listen and record this level of social detail)

Review of systems

Skin-acne in youth, some dryness

Head-eyes, ears, nose, and throat (HEENT)-no complaints

Heart-no complaints

Chest-short of breath with one flight of stairs climbed


Pelvis-no complaints although no sex for a long time

Extremities-leg pain on walking more than one block

Central nervous system-anxious with trouble sleeping


Physical examination

Blood Pressure 210/120.  Pulse 100/min with irregular beats  Respirations 25/min Temperature 100 degrees F  Weight 248 pounds   Height 5’10”

Skin-acne rosacea over the nose and cheeks; marked cracking and fissuring of the facial and neck skin

HEENT-pharyngeal leukoplakia; normal thyroid without nodules

Heart-normal sounds without murmurs, rubs, or gallops

Lungs-clear to auscultation and percussion

Gastrointestinal-normal bowel sounds; no bruits

Extremities and Back-normal range of motion but mild weakness noted and joint limitation of the knees

Genitourinary-normal male

Central nervous system-all intact reflexes and cranial nerve functions

Electrocardiogram-ST elevations in the anterior precordium suggesting recent anterior myocardial damage

Cardiac panel-evidence of recent myocardial damage

Chest radiograph-slight cardiomegaly and no congestion

Remainder of laboratory tests normal except for mild proteinuria




  1. Acute myocardial infarction due to atherosclerotic vascular change and hypertension
  2. Hypertension
  3. Cardiac risks including smoking, family history of heart disease, and obesity
  4. Acne rosacea
  5. Probable degenerative joint disease of the knees




  1. Present to attending physician
  2. Consider cardiac catheterization and angioplasty with clot-resistant stent placement
  3. Lifestyle interventions when feasible

Clinical course summary


Mr. A was initially evaluated by the attending internist, and then referred to the staff cardiologist.  Consent was obtained for a cardiac catheterization.  The initial catheterization was difficult to interpret although severe left main coronary artery disease was suspected.  Because of technical limitations at the receiving hospital, consultation was sought at the referral center, a hospital in the same health care group some ten miles away.  Pain care and other medications per protocol were given, and the patient was transferred to the referral center. 


At the catheterization laboratory of the referral center, staff prepared Mr. A for a second examination.  He was alert but in moderate discomfort.  His family followed along but was asked to stay in the waiting area, and told that the doctor would consult with them after the procedure was concluded.  His wife and children huddled together in the family waiting room, and were clearly anxious according to a nurse’s record. 


The doctors found the main artery blocked, and opened the narrowing.  A stent was placed, and a second further down to prevent the vessel from closing.  Three more stents were placed in other narrowed vessels.  During the procedure heart rhythm abnormalities were common, and Mr. A continued to have pain worse than any he had ever experienced.  The area in his groin where the catheter had been introduced bled moderately after anti-coagulant was given.  The procedure was concluded, and he was sent to a coronary special careunit.  The interventional cardiologist met with the family, and assured them that the procedure went well, and he expected that Mr. A would be feeling better in the morning.


Mr. A continued to bleed from his groin.  Over the next few days his fever undulated reaching 102 degrees Fahrenheit.  He came in and out of consciousness.  He was taken back to the catheterization lab on the third day, and one of the stents was noted to have migrated down the vessel resulting in a new blockage and was un-retrievable.  His bleeding continued and he required multiple blood transfusions.  Pus was found in his groin, and blood cultures revealed bacterial growth.  His heart failed to improve leading to pump failure.  On the forty-fifth hospital day he died.  He had lost consciousness after a month, had required ventilator support to breathe, and his kidneys stopped functioning requiring dialysis.  His family was devastated.


At autopsy, findings included multiple organ failure (the heart with a recent infarction and stent migration as noted, the kidneys, and the lungs were noted to be in a dysfunctional state), pulmonary embolus of the left main pulmonary artery (a new finding), and evidence of sepsis with endocarditis.


Also included in the file was a lawsuit filed a few months after the death.  Negligence was claimed in general care (though the stent migration, hemorrhage, sepsis, and pulmonary embolus were the focus), and all the caregivers as well as the hospitals were named as defendants. The suit was settled out of court five years after it was first filed.  The family was awarded $2 million dollars (year 2000 value), and the lawyers received half of the settlement.  Most of the judgment was paid by insurance carriers for the second hospital and the second interventional cardiologist.

Dr. Middleman

The case of Mr. A. is an example of care around the turn of the century.  The care and outcome were exceptional but not unusual complications for few of those receiving treatment.  This example is not meant to shock the hologram viewer, but serves as an example of a complication of care delivered in the past.  As this author poured over records, there are examples of people who received care that they did not need, of people who received care not recommended by the guidelines of the time, and people who did not receive care recommended.  These examples represent about half of all care given or withheld.  It must have been a difficult time.  While outright fraud was unusual, examples of abuse, negligence, and poor quality care without adherence to existing guidelines abound.  The incentives of the time favored frequent and un-necessary treatments.  Often the elderly patients were subjected to spectacular and painful care modalities that only prolonged the eventual outcome of death.  So many examples tell of people endangered by incorrect medication use, improper interventions, lack of proper interventions, and un-necessary surgeries.   This was “the best of times and the worst of times” (Dickens) for medicine if we take into account that some received advanced and excellent care while others received wasteful, abusive, fraudulent, and inappropriate care.  These problems occurred in the poor and the well-funded patient


What contributed to uneven distribution of care?  The practitioners of the time were bright and caring individuals.  They lived in a era of advanced pharmacological agents, pharmaco-genomics, wonderful new computational devices, and genetic revelations.  What contributed to care that resulted in harm to their patients?  Surely they wished to improve the health of those they served.  The great majority of practitioners meant no harm.  But harm is evident in these records, pain and suffering abounded, and unsafe fatal practices were the rule.  In the previous one hundred years health in most countries had been sustained through adequate nutrition, treatment of infections, immunizations, and sanitary water and sewage treatment.  What gave rise to such irony, such pain in the face of plenty?


Before we compare care to that given today, let us examine the way care was delivered by our predecessors.  How did they receive rewards and reimbursement for their services?  How did they use available information?  Good intent is assumed.  These resourceful creative people meant well but their delivery process for medical care was deeply flawed, and led to countless disastrous results.


After undergraduate preparation concentrating in math and science, medical students began a four-year academic study.  Once tested and certified in the sciences of pharmacology, physiology, pathology, biochemistry, genetics, immunology, and other pertinent areas, the medical graduates spent years in post graduate practice under strict supervision.  They then were released from training with minimal supervision and maximum responsibility.  They were loosely supervised by peers in their field without outside review.  The peers were subject to pressures from the threat of libel, the threat of practice retaliation with loss of consultations, and other income threatening actions.  This review situation was far from independent.  Inter-dependence was the rule.  Independent outside review was not possible, and certainly not welcomed by most medical societies.


Since they had no further review other than cursory examinations at infrequent intervals, they were free to practice un-supervised.  Though guidelines were available, they were not followed by most practitioners.   One study of the time showed that people received preventive services recommended by guidelines of the time less than 50% of visits.   In fact, the ideas of performance measurement and care review were taboo.  Why this reversal in academic rigor from student to practitioner?  While hospitals grew larger and formed into corporations and multi-facility systems, medical practice remained a small business or a cottage industry.  These practitioners contracted with insurance plans to form networks of doctors who cared for people.  The insurance plans grew larger, and merged with others to form health plans that provided coverage for one in ten Americans.  Though some physicians saw the wisdom of larger groups and group practices, most stayed in single or small groups to maintain autonomy. 


Dr Middleman was the internist who cared for Mr. A.  Dr Middleman attended medical school graduating in 1974.  He studied clinical medicine at a highly rated program at the University of Chicago.  There he learned the procedures of the time, learned to get information from patients to help resolve their “complaints”, and left the University with a guaranteed salary offer to practice in nearby Deerfield.  The hospital there offered him $150,000 base salary (year 2000 dollars will be assumed henceforth), and set him up in their adjoining office building.  In a short time, he was earning twice his base salary, and was seeing forty to fifty people per day.  His work was hard, and he spent 14 hours a day between the hospital and his practice.  After finishing residency and earning $15,000 per year, he felt he was doing well, and would pay off $100,000 in student loans in a few years.  While academic concepts were foremost just a few years before, now the concerns were mostly related to the business of his practice.  Which new machines should he buy?  Should he lease radiograph equipment?  Did he need more assistance with accounting and contractual legal advice?  Where would he store the growing volume of paper charts?


His wife saw less of the doctor, his children were asleep when he got home, and he was a ghost in his own large new suburban home.  He began drinking heavily at times, he was wined and dined by pharmaceutical representatives, and he often went to ball games until all hours.   He started going to late night parties.  Marital indiscretions were common.  All this carousing left him tired and gruff during the day.  He would verbally attack caregivers at the hospital.  He became careless.  Over the years, he no longer followed guidelines, and resorted to patterns from years earlier despite advances in the science.  Any complaints were met with vicious reprisals.  This behavior was rewarded with greater reimbursement.  The more mistakes he made, the more he was paid.  The more tests he ordered, the more he charged.  Wasteful practice was rewarded by larger payments.  With these incentives, his practice grew to “rainmaker” proportions.

His autonomy was great.  His rewards were prodigious.  His abuse of those around him was scathing.  Ideas like “pay for performance, group practice, and digital records” were reviewed.  What was in it for him?  He did what was necessary to renew his license to practice, and to maximize his revenue.  Performance was the bottom line.  Performance was paying his employees.  Performance was what he wanted from his cars, his offices, and his patients.  Performance was what he demanded from the hospital administration in maximizing his income, and buying those machines from which he made the highest profit.  Both the non-profit hospital and his practice did well from the use of the machines.  Vendors brought him machines he would use in the office, and taught him how to make the most money per procedure.  Everyone benefited.  He helped “raise the water level to float the boats”.  He was a mover and a shaker, or a rainmaker to continue the water analogy.  The idea that a doctor would be primarily motivated by greed was unthinkable.  The idea that a practitioner would be addicted to drugs or alcohol likewise was unthinkable.

When consultants would balk at performing procedures or suggest safer less invasive alternatives, he found new consultants. His life was great.  When he billed a procedure code to the insurer or government, his reimbursement flowed back in ever increasing quantities.  The more he did, the more money he made.  If procedures were complicated or if infections occurred, he made more money.  If payers reduced the procedure rate, he performed more procedures.

He and his bookkeeper had two sets of books; one for the tax man, and one for themselves.  The idea of a group practice was anathema.  He had developed his own style, and expectations.  He was not about to share these with others or share his income with someone else.  Why should he put money into electronic records, guidelines, or improving the safety of his practice?  If a patient left a nursing or rehabilitation facility with unnecessary medications, his pharma stocks would continue to do well.  He did not want to rock the boat that had become his way of life.  He was operating outside the law that governed others, and answered to no one.  Was he doing the right thing?  He certainly saw himself as a fine practitioner and a “good” guy  Mr. A saw him the same way up till he lost consciousness and died in an untimely manner.


He was not alone in the year 2000.  For reasons similar to those above, few practices advocated change.  There were some to be sure.  There were successful large groups throughout the country that put in electronic records, guidelines, and focused on making their practices safer and better.  They were in the vast minority.  Less than 5% of practices pushed these advances.  Most were like Dr. Middleman, and favored inertia, lassez faire, and keeping government out of practice.  The number of physicians with libertarian philosophies sky-rocketed.  Meanwhile the profession limited entry into practice to maximize demand and minimize supply.  Any threats from ancillary fields such as nurse practice or physician’s assistants were met with legislative gridlock.  This gridlock was maintained by massive contributions to legislative lobbyists.


Did Mr. A’s family feel better once they had the insurance settlement?  Did they resume their lives, and become fulfilled, grateful, and appreciative citizens?  Did medical care improve as a result of the lawsuit and the outcome?  Were they able to trust their caregivers if future health problems arose?  Did they minimize their own cardiac risk factors? Did they begin to eat right, exercise, and focus on preventive strategies?  Were they a close knit family after Mr. A. died?   



Letters to the editor

Mrs. A


A letter written by Mr. A’s wife to a local newspaper was found in the file. (Anachronisms such as newspapers will not be dealt with in depth but are listed in the electronic notes attached to the holographic program).  View this letter with Mr. A. and Dr. Middleman in mind.


“My husband was cared for in this city’s finest hospital, and by the finest doctor.  He suffered a common problem, and we thought he would be back home quickly.  He never came home.  He died after a series of complications from poor quality care.  My family and I are heart broken, abandoned, and find it difficult to trust any health care providers.

Now after difficult years in court searching for truth and justice we know a few things we wish to share.  The city’s “finest hospital” is a billboard message or an advertising slogan that does not exist in any measurable way we would understand.  The city’s “finest doctor” means nothing in any measurable way we would understand.  There is no objective system that measures such performance for hospitals or doctors in a meaningful and transparent way.  I would not be able to prevent past events even if they occurred today.

When will we stop shedding tears, when will we quit wasting dollars, and when will we demand accountability from our health care providers?  These demands must come from outside the provider gates.  Those inside have too much to preserve and do so with their inertia, their circled wagons. Please join with me in the coming elections to demand accountability and transparency.  Our families, our country, and our progeny are counting on us.”

The Medical Society Response


“We note with regret the letter submitted by Mrs. A.  Our heartfelt condolences go out to her and her family.  However, we must comment to the grieving widow.  The art of medicine has a long and hallowed history.  Our doctors try to do no harm and relieve suffering.  The vast majority of physicians are hardworking and well-intended.  They work long hours, and seek reward in the relief they bring to their patients.  The road to achieving a medical degree is hard, and life after the receipt of the degree is difficult.

We work tirelessly to master the principles and practice of medical science.  We take examinations in our chosen fields to demonstrate mastery.  We apply these skills in our day to day care.  We gain trust through reliable helpful advice and care that continues sometimes for decades.  We are accountable on a daily basis.

People now talk of a change in the way we are reimbursed, the quality of care we deliver, and the distribution of care to the entire populous.  We agree that excellence should be rewarded.  As the vast majority of practitioners are above average in their care of patients, we want recognition based on quality of care.  Our concern is how to measure quality of care.  Many of us who care for the disadvantaged or those of us who work at teaching medical centers are concerned that the severity of illness of our patients would not be properly weighted in evaluating the care that we give.  We are concerned that comparisons would not be fair.  Before we put information in front of our patients about the care we give, let’s assure them that the comparisons are without bias, the information truly represents quality of care, and measures used are widely accepted as valuable evidence.  We agree that the old measures of affability, ability, and availability are no longer the sole guides.  Before we totally discard these watchwords, let’s add to them with widely accepted standards.  Let’s assure that people understand the additional standards.

 We are committed to a safe and caring medical environment, and hope that we are making the world a little better each day by what we do.  Again we express our sincerest condolences to the family and stand ready to help them in their time of need.



Dr. C., Medical Society President



Cook County Hospital Association


The members of this association are proud of our record.  Our hospitals are very effective and safe institutions of medical care.  Many of our members are world renown.  Quality is the watchword in all that we do.

We have the finest facilities with every modern technology available.  Our staffs are credentialed in their specialties, and are some of the best in this country.  The quality landscape becomes more rigorous with each passing day. Our members are all certified by the Joint Commission on Hospital Accreditation and the government’s senior care program.  We all employ staff to continuously improve care delivered.  Just in the last year programs were added in heart care and surgical care.  We have joined registries to give information about our care, and compare that care confidentially with other similar institutions.

The public should rest assured that we are doing all in our power to improve the safety and quality of medical care.  Our community trusts the work we do.   Members of the community sit on our boards and direct our work.  We continue to be a health care community committed to delivering excellent world class health care.


Mr. R., President, Cook County Hospital Association



Excellence in Medical Care or EMC

What a bubbling cauldron poor Mrs. A. found herself in alone and under attack!  Distraught, bereaved, and abandoned by friends and community, she struggled to understand what had happened since the death of her beloved husband.  She neglected her person, and her children.  Her minister came to visit to bring her solace.  Reverend S. consoled her, and advised that she lay down her sword and shield, and work to improve care for all.  While she was comfortable in the blanket of outrage and suffering that she had wrapped herself in since her husband's untimely demise, she apparently took the kindly advice to heart. 

Over the next few years she founded the non-profit foundation, Excellence in Medical Care or EMC. Her organization developed a curriculum for community groups and individuals.  The group researched all available sources to better inform people about the health care system.  They trained and fielded staff across the country to help people understand their choices and interpret the complex safety and quality information sources that were becoming available on hospitals and doctors.  They developed standards for care where consensus was found, and brought together people to develop consensus where it had not yet been reached.  They searched the world for better ways to deliver care.  What were their barriers?  What difficulties did they encounter?  What roadblocks had to be removed?

The organization met obstacles in every path.  When they showed the wisdom, and financial payback of switching to digital records or the so called electronic health record, an avalanche of legal paper blocked their way.  When they showed the folly of multiple administrative systems or payers versus the single contracted regional payer shown so effective by so many countries, a corporate firestorm scorched their path.  When they suggested regional resource planning to avoid the technology explosion that had resulted in medical imaging on every corner and surgery centers outside the hospital walls, another corporate firestorm erupted.  When they pointed to the lives saved by consistent use of guidelines and consensus care, they were met with professional outcry and jeers of meddling incompetence.  When they suggested that the billboard reputations and advertising slogans were just that, their sanity and credentials were questioned as well as their importance to the communities.  They realized the importance of a new reality.  Whatever had gone on in the twentieth century, had missed the mark in providing most people with safe effective and efficient care.  They realized that only by focusing on the consumer, the patient, and the person in need would they change the world of care.  They also realized that incremental change was no longer possible.  Transformational change was the answer but revolution might be necessary.  In a similar situation in Russia in the twentieth century, the dictator Stalin had killed all the doctors, and taken control of the health facilities.  The Chinese had dealt with the situation with the Cultural Revolution.  Most European countries had similar situations, but changes in the health care systems had resulted in bloodless revolutions.  How would this great country deal with the vast change that was needed, and keep high quality practices while discarding those of less or no value?  How would they reduce harm to those cared for?

Letters from beyond; imaginary conversations Mr. and Mrs. A had after his death recorded by Mrs. A


“I have missed you so much.  I know that it is futile to wish to have lived better.  If I were alive today I doubt that I would change my habits.  No smoking, eating when hungry, regular exercise, and who am I kidding?  If I were alive today, I would continue to live as I always lived.  I loved chocolate, big juicy hamburgers and fried potatoes, and thick rich milk shakes made with whole milk.  What will you do dear to turn the tide?  Our country and our corporations have grown fat and content.  We encourage all the disease promoting things.  We encourage overeating, overdrinking, smoking, gun violence, and automobile recklessness.  We point out on digital maps the locations of every eatery.  We discourage exercise, personal responsibility for our actions, and abstinence from any desire.  What will you do against all the messages over the ever present social media encouraging us to continue our current lifestyles?  Where will you focus to change our lives?  How will you pierce the veil of professional wisdom to reveal the self-interested greedy and prideful forms that reflect institutions of current practice and knowledge?

When I was taken to the hospital, I was not in good shape.  I trusted that the doctors and nurses would heal me, and the hospital would provide them all they needed to succeed.  Now after death I know I was wrong!  One error after another occurred.  I felt like I was letting you and the doctors down by my failure to improve.  Infections, clots, migrating stents, and time took their toll.  How are the children and how are you?  I miss you all so much.  I miss your warmth, and the hugs and caresses.  I am so cold without you.”



“We miss you too.  I am so angry, and fault you for the life you lived.  I fault the doctors and the hospital for their poor care confident incompetence, and lack of compassion and human kindness.  My anger knows no limits, and overflows into pools that feed raging rivers which overflow their banks and rampage as they run to the sea.  As one lonely woman, I have little power to change our world.  I know that as we struggle with obesity in our children, children in other countries are not obese and some are underfed or starving.  What kind of God would allow this?  What kind of justice would allow such blatant mal-distribution of fuel, water, food, and medical supplies?  These words pour from me like lava from a volcano, and I understand the concept of a dragon lady.  I am so angry.

I look around, and am amazed at how seemingly happy some are.  The doctors and the hospitals fight against change which would improve the quality of care they deliver.  Corporations seem to be enjoying record profits, and see no reason to reign in big tobacco companies, gun manufacturers, and liquor producers.  The green movement takes a back seat to quarterly profits.  Public transportation is under-funded while we pay to repair every needle sized road in the country.  Our fuel is taxed at low levels so we are able to drive any vehicle no matter how inefficient and no matter how far the trip.  Our cigarettes, guns, and alcohol are taxed at low levels so it is easy to develop addictions and death promoting strategies.

Most people who have not heard my angry rants, say I am depressed from the events which began when you died.  They want me to start on medication so that I will smile, and be less upset and sad.  I may take their advice.  Besides missing you, and trying to raise the kids without you, I am doing well financially for now.  Your insurance policy has smoothed the road but that money will run out in the next year or two.  The kids will have to go to local schools or go to work.  Since the boomer generation is so dependent on others, there will be plenty of work in the trades and health related fields.  I will go back to work for the salary, companionship, challenges, and benefits.  It is a bit disappointing to stray so far from our plans.

Who have you met?  What stories have you shared?  Should I continue to seek change?  Am I heading in the right direction or has my bitterness, sadness, and anger clouded my vision? I need your advice and gentle listening partnership more than ever.”



“I have talked with legions of elders.  Many of them tell of a new form of torture they experienced.  Most feel that death is far better than the life they were forced to lead.  Mr. L. tells me that he apparently had a stroke and was no longer able to express or care for himself.  His kidneys failed as well.  He was put on dialysis to cleanse his blood and perform the work of the lost kidneys. He wanted so much to be left alone, and to sink into coma.  Eventually his heart stopped, but when he awoke the room was full of machines, and now a machine breathed for him.  He was poked and prodded, and had tubes from every orifice and some new holes that had been created in his bruised and paper thin skin.  Others claimed they had also suffered this treatment on awakening from the white light that had filled their vision.  When they awoke they found themselves unable to express themselves because a tube prevented their vocal cords from moving.  No matter how hard they tried they were unable to make their wishes known.  The caregivers both cared and thought they were doing the right thing, or were indifferent to the suffering before them.  Some overheard those around them say that as long as insurance payments held out, the care would continue.  Some overheard talk that the more tubes they had attached to their bodies, the less chance they would have to survive.  Those poor elders prayed to be left alone to die.  What kind of system allows and even fosters shame and degradation?  What kind of society bankrupts itself to pay for unnecessary treatments?  Most of the so called caregivers go on from day to day participating in this ritual care without considering the dire and un-intended consequences on their souls.  What have the patients done to them that would spawn such wanton disregard for the dignity of human life?

 Mr. L now follows Dr. X., his tormenter around each day.  It seems that Dr. X makes a point of seeing each patient each day.  He had learned that Dr. X does not try to get people to independence from the machines, but instead keeps them weak and dependent to collect payments from insurance of these dead souls.  Dr. X. seems to have become quite prominent at the hospital, and has become friendly with the administrators.  They apparently admire his practice patterns which contribute so richly to their bottom line.  Perhaps he never learned to wean these people from their mechanical aids.  Perhaps he views his torture as care and mercy.  Perhaps his incentives are more sinister.  Dr. X. has a large following of elders who have already scheduled daily meetings with him when he arrives among us.  

Moral judgments oversimplify what is going on in the world.  The processes are so complex and confusing.  At the end of the day, we listen to those who have experienced the medical system.  One wonders how often those who make up the system listen to the living breathing patients about their experiences.  How often do the care givers sit behind mirrored glass, and listen to those who receive care?  How often do they hear from those who have received care when they are less fearful, and away from the medical presence? 

It is said that surgeons always have successful days.  All of their operations are well planned and well compensated.  Removing a gallbladder is more enjoyable to many surgeons than a round of golf.  The folks up here have a different view.  As with Mr. A., death follows days of complications from work poorly done.  They say that most surgeons oppose evaluation systems that would give people some guidance prior to an operation.  Rarely do people know that there is discretion and choice in surgical care.  Most have not been apprised of their choices.  Most have no idea that some options are safer than others in terms of facilities, prostheses, implants such as pacemakers, and procedures.  Safety should begin with safe choices.  My dear, this is where your work is critical.



Dr. W. and five tenets of care

Dr W. is among us, and his vision of care is guided by these principles.  Care should be ethical.  Here he means that it should be the care you would give to a loved one.  He differentiates from the legal definition of care, which society and laws dictate; and care that is a societal standard or that which is the norm in a particular locale.  He teaches that we should be cared for as we would care for a child or parent we love.

His second tenet is that care should be based on studies which have shown the best outcome with a particular approach.  This care would be the result of careful deliberation and ongoing study to always present the best and most current approach.  Fads, cures that appear too good to be true, and the loudest voice in the room touting the newest and greatest are to be avoided unless they pass the “best outcome” test.  This approach takes patience, but leads to the best care.  He notes that many medical specialties have supported such guidelines in areas such as cancer prevention or chronic disease care.

Tenet three is that care should be of value.  Most people have alternatives in mind when they consider using their own hard-earned money.  Efficiency and prudence, avoidance of wastefulness, and care one would deliver to one’s loved ones must be considered according to Dr. W.

The fourth consideration is that all care should be directed toward sustaining or returning one to health, rather than fighting the inexorable ravages of disease if possible.  Prevention is the watchword.  As with any superb system, the body and mind of a human being are incomparable.  When disease supervenes or injury occurs, the work of repair is utterly more complex than that of maintenance.

The last principle he shares with us is that people chosen to pursue health care careers must first love other humans.  They must be responsible and thoughtful but first they must understand the duty to “do no harm”.  Somewhere over the past one hundred years this admonition has been lost, and tremendous harm occurs each day.  They say that the number of people who die from medical errors is the equivalent of an airliner with three hundred passengers falling from the sky to their deaths each day.  How is it that airline travel is so safe in our country, and medical care is so dangerous?  We need our clinicians to return to their roots as healers, and those who “do no harm”.


Your path will not be easy.  A Medical Industrial complex has grown up.  Surrounding the doctors (who mostly still practice in a primitive way, and are members of a cottage industry) is a predatory industry fueled by insurance payments and premiums which rise in a rapid upward spiral.  These payments fuel tremendous waste.  This waste is not harmless.  The overuse of radiation has untold effects on future generations by alteration of germ cells in the ovaries and testes of the young.  The over-use of medications which flow freely to all areas of the body alters our present and future as well.  The lack of system oversight leads to a legion of abuses.  You will not be effective in combating all these ills.  Your path is to raise your voice and campaign for a return to dialogue based on Dr. W.’s tenets, and those you add through your love of mankind. 

The way you seek will be best found with an open mind.  Appreciate our children’s smiles and laughter, find interest in changing to a better way, be resourceful in working with the “brick and mortar” modern day empires that so called non-profit and for profit hospitals have become, be creative in finding new avenues for corporations to pursue, and be optimistic about the outcome of your work.  Your wisdom, energy, and grace will be rewarded.  Countries all around us in this world have developed better approaches with better outcomes and lower costs.  We will find our way back to the center of this dialogue.  Help the majority of academics get their heads out of the sand.  Help them take up the challenges we all face when our eyes are open, and our hearts beneficent.”



“Your words are a blessing, and give me hope to pursue what is right and what is good.  I remember when we cared for your mother, D. as she lay dying.  Her breathing was labored, and the doctors wanted to put her on a breathing machine.  She was absolutely against this plan, and instead chose to die surrounded by her family in the absence of machines.  She was so verbal all of her life, and did not want to be deprived of the ability to express her thoughts in her last moments.  She died quietly with audible breathing surrounded by children and grandchildren in perfect peace and with every wish granted.  She was a picture that would define the word, “dignity”.


Truth to Power; “Getting and spending we lay waste our powers” … W. Shakespeare


I did not remember dreams in years past.  After awakening in the middle of the night, phantom characters were exiting stage left.  They would leave quickly before giving up their meaning or import.  That was before the Nano chip was implanted.  Now with this new technology all dream content is revealed.  All thought content is revealed.  In fact, your author is not using hands at times to bring this information to you.  As you know, after our great leap forward in the “Golden” period, we have the ability to bring all thought content to the conscious mind.   Thoughts are automatically recorded for later viewing and reflection.   I will not dwell on the privacy aspects of our new technology as there are Institutes and government agencies devoted to the many questions spawned.

What was Mr. A.’s role in Mrs. A.’s mind?  Did his imagined counsel shape her later actions?  Did she have dreams such as this?  What influenced her to shun criticism and censure, stand brave against threats to her family, and continue her struggle?  As we have noted, vital statistics of the period showed poor performance in the delivery of health care compared to many other nations.  Figures placed the countries’ health care worse than thirty-seven others despite world dominance in weaponry, space adventure, and Olympic sport.  How was it possible that such premier technology and world leading resource consumption, was able to care for people so poorly.  Overtreatment of the resource rich and under treatment of the poor was the pattern.  Driven by these facts, she held the mirror high, and reflected the true face of care.  She was courageous and undeterred.  Her strength became super-human, and days that knew no end. 

Her organization felt the importance of truth telling to the powerful.  They developed region specific comparison tools that ordinary people used to see differences in cost, mortality, infection rate, surgical outcome, procedure outcome, and satisfaction.  More importantly they re-framed the discussion from acute care of people already affected by diseases such as diabetes and atherosclerosis; the group re-shaped discussion to maintenance of health and prevention of disease.  They pointed out superior outcomes in other countries which used far less resource expenditure, and suggested alternative processes to follow in care delivery.

Armed with new useable data, people began asking questions of their providers.  Why this medicine, why this procedure, why this facility?  What is in my self-interest, and what is in yours?  How might we align our interests?  Massive conflicts of interest were uncovered, and addressed as in an editorial found in the leading newspaper of the day:


“The echoes of the stock option-dating scandal are still in our ears.  Executives of health plans sought even greater compensation by dating share values to their lowest value on acquisition only to sell them at their highest value which resulted in windfalls. 

This happened when fifty million citizens were without health care coverage, and countless more were under-covered for medical emergencies.  This happened when networks of care providers were made available by these plans with no regard to regional variation or the quality of care provided in a "buyer beware" scenario similar to haberdasher, jewelry, or soap sales.

Now we learn of additional scandals linked to financial incentives.  It seems that doctors are people first, and governed by the same laws of human nature that govern us all.  First we find that oncologists or those doctors we entrust with our cancer care have been receiving over half of their generous income from the very drugs given to treat the cancer patient’s they serve.  In many cases they have been using agents from which they derive greater good than their patients.  Cardiologists have been using expensive procedures, devices, and operations based on the compensation they receive rather than what is best for their patients.  Orthopedists are putting in artificial devices to replace joints or structures based on the reward to themselves, and not their patients.  Numerous other specialists and generalists have also become accustomed to prescribing and injecting medications based on their own financial well-being, and the “do no harm” dictum seems no longer to apply. 

These are well meaning people we all know and respect.  Is it possible that these well documented accusations have merit?  It is not only possible but probable that we have a system built on financial incentive to do the wrong thing.  The system needs to be re-built.  Financial incentives need to be given to those who do the right thing at the right place and the right time.  Health care is not a business where all product sales should be rewarded.  It is a discipline where judgment and thoughtful study go hand in hand with action.  Those medical leaders who must be heard have cried that outcomes vary widely by place of service, that people are dying unnecessarily each day in our hospitals from poorly developed processes which do not follow current guidelines for care, and that variations in outcomes by race or racial disparities are significant.  This organization backs the health platform proposed by EMC, and recommends that governmental study groups be formed to propose a new solution for this country.  The current system marked by greed, territorial protection, and poor quality care is no longer tolerable.  In the next election, the party and the candidates who work with these new recommendations need our support.  We anxiously await the outcome.  Our lives depend on it.”


The editorial had little effect and went mostly un-noticed.  The media of the time had been “in bed” with others, and had developed a simple formula along with the government.  If you keep people excited and on the edge of their seats, and cater to the rich and powerful you will succeed financially, or in the words of a Republican Presidential Candidate of the day, “you will be winners”.   If you want the public awake and aware when the sponsors advertise their products at the end of the news segment, you must do it with simple stories.  In these stories there is a hero, a villain, and a victim.  Facts only confuse the public and history of past events and proclamations bore them, and should not be presented unless they support your or your patron's point of view.  Keep them anxious and outraged, show them fires, murders, abuse, and storms, and then present them with cures, fantasies, and more merchandise to buy.  Show them some grey-haired physician who has name recognition in order to pitch medicines.  "No money, no problem", let the debt accumulate for the next generation.  In fact, the drug sellers had become the main sponsors of the media, and certainly did not want people to understand what might be in their best interest.  In these times, the great irony of a campaign against illegal drugs, “just say no” was not lost on those who understood the nature of the market manipulation and proliferation of legal drugs.

EMC and Mrs. A. were resolved to help people understand their situation.  Like calves led to slaughter, most people were not involved, until some pain or fever brought them into a provider of care.  Like a freight train off the track and plowing into the field of freshly turned earth, the marketing juggernaut would only be stopped by its own weight and missed path.  The sentient of the country understood how off course the nation had become.  Comedians made fortunes with parodies of the government, and pointing out the glaring ironies caused by a self-interest based corporate system of health care.  In order to distract the public, wars were fought with phantom enemies such as family planning, issues were made of sexual preference, and all situations were portrayed as matters of good and evil.  Heroes, villains, and victims abounded.  When health care was addressed, it was only to give equal access to all without regard for the quality of that care.  In the meantime, the imbalances continued.  Resources were consumed in far greater quantities.  Consumers were advised to exercise, diet, and avoid smoking cigarettes and drinking alcohol on public radio.  On every other media outlet, they were advised to use all manner of new and expensive medication for every symptom.  New medications were often simply as good as those that came before according to the FDA, but their cost was much greater.  Massive amounts of fossil fuels were used as engines continued to do more and more of the work of people and animals.  People went about their daily lives, and followed the path of least resistance.


The dog who is a constant companion is restless.  Her expressive face tells me she wants to go outdoors.  Though hesitant because of the cold air and strong wind, her will prevails.  She is persistent, and soon I have put on a hat and coat, and led her out into the brisk air.  What would induce the author to digress in this fashion?  I leave this for the reader to deduce.  As she sniffs the grass and bushes, I reflect on the turbulence of the times when so many people sought so much power, wealth, and control in an arena where these goals were not expected by those cared for.  People wanted health, goodness, and care, and expected beneficence in care givers.  She is barking now and hopes to have found a friend.  I greet the fellow dog walker, and pass by on our usual route.  Gracie is like a personal trainer.  She brings her human on these walks weaving in and out of the neighborhood, on her daily inventory of scents.  She reminds of a world beyond health care, and of other priorities and interests.  I take time for her concerns, and she sleeps quietly while I pursue mine.  She helps your author see the forest and the trees.  The leaves of linden, oak, maple, elm, and ginkgo are strewn on lawns and streets.  They have become yellow and brown, and matted from the snow and ice of recent days.  "For Sale" signs are posted here and there, and pique interest in transitions.  Houses built by famed architect, Frank Lloyd Wright come into view around some corners, and remind one of the craftsman era in homebuilding.  Other signs remind one of the season, though Christmas trees in the street tell of recent days of joy now past.  Who would have foreseen the changes?


Change is inevitable but rarely seems to be so to humans.  We cling to what we know desperately.  Who among us jump happily out of a warm bed on a cold or rainy day?  We live cycles of birth, childhood, play and work, adulthood, and decline to death.  We celebrate holidays month after month, and year after year.  We deny the future but reflect on good times past and present.  Our nature is to find balance and stability.  Most of us fear change even when the present and past are far from perfect.  We live with a level of pain and abuse in order to avoid what we do not know.  Do we fear that the change will make our lives more painful and more abuse prone?  When a system develops increased complexity, do we fear that any change will have unintended and unforeseen consequences and circumstances?  Despite corporate and government "right speak" most of us fear change.   But change occurs second to second. Change seems to occur faster as time progresses, and faster as we age.   In fact, change did occur but more of that later.


How should we measure incremental change?  Should we measure with seconds, minutes, or hours?  Should the measure be our daily routines such as trips to the mall, trips to school, trips to the market, trips to the hardware, or trips to the pharmacy? Perhaps we should measure by birthdays, hospitalizations, awards, or honors received?  The mundane should not be forgotten such as trips to the garbage, trips around the neighborhood with the dog, trips to re-cycle, trips to work with government, or trips to funerals.  In medicine in the last one hundred years incremental change was measured in technology leapfrogs such as computerized tomography to positron emission tomography, new buildings added to massive brick and mortar hospital complexes from New York to Texas, and new procedures and pharmaceuticals from penicillin and far beyond.  Incremental change was much more difficult to view.  We saw such change in acceptance of common electronic interchange standards, ethical rules for practice, practice guidelines for diagnostic procedures such as digital mammography, development of patient safety practices, and development of accepted measures of quality in practice. 


With all change there is confrontation with those who hold tightly to the present and past.  Why do they hold with such steadfast determination?  Is the struggle comparable to pulling the covers off a warm child who is late for school?  A balanced analysis must include all factors involved. 

Dr. C. from the medical society would point out that what we do is time tested, has worked well in the past for us and our teachers, and is accepted as the community standard for best practice.  He would further assert that until such time as there were accepted new standards, those which his members agreed on, we should hold dear to our present practice in the best interest of our patients. 

Dr. W. of celestial acclaim might differ, and suggest that current practitioners were unable to accept new methods because of their pecuniary interests, their lack of external regulators and standards, their unusual situation that allowed them to bypass necessary changes in outcome-based practice, and their lack of scientific rigor and beneficence.  He would assert that their inertia had led them to play the old game of "king of the mountain"; once entrenched in power they were unable and unwilling to allow new practices, new practitioners, and new ideas to flourish.

Dr. C. would counter that it is easy to criticize with hind sight, and heavenly wisdom but most practitioners have always done the best they could for their patients, and have placed their patients’ interests above their own.


Here lies the problem for the entrenched.  The practitioners of this era were cast in a defensive role.  Unable and unwilling to develop dialogue with their critics, and medical policy theorists, they dug deeper in trenches to protect their way of life.  When viewed from England, France, Russia, Japan, China, or Canada the situation was much clearer.  From these different views it was obvious that the complex quilt of American medical care was obvious and disastrous.  They opined that Americans had no system for delivery of medical care.  They saw super-optimal spending for sub-optimal care.  Early in the twenty first century they reversed a previous trend, and either left the U.S.A. after training there, or never left their own countries of origin.  Some claimed that excessive anti-biotic use had led to new and more virulent infections and allergies, some claimed that overly aggressive use of technologies and procedures were resulting in unfortunate results, and some claimed that racial and ethnic disparities had ruined what was once a land of opportunity.


Why had change occurred in these other countries as opposed to the U.S.A.?  Was this another signal of the waning greatness of this country founded on liberty, equality, and freedom?  Had people in their cynicism given up on the hope needed to achieve these ideals?  I will share more on this later.

Now the Fox Terrier at the end of the leash has indicated that I am not paying enough attention to her, and should move along down the street to the next fire hydrant or tree.  She usually likes to be out for at least thirty to sixty minutes.  As a personal trainer, she finds that her human needs at least this much walking each morning.  When we start out on these walks, she strains at the leash to reach all the invisible sites of chemical nasal attraction.  The cooler the weather, the more energy she shows by her pace and activity.  Her characteristic Fox Terrier curly white, russet, and gray coat with gray spots along the back seems to keep her warm.  As we go along she slows, and by the end of the walk she is at the left side and no longer straining.  The tension felt in the leash when she needed to relieve herself has relaxed. 


Our circuit complete we arrive at the library.  Gracie shakes off her walk collar once it is detached, and curls up on a padded chair nearby.  It is a sign of enlightenment that libraries now allow companions of the canine variety.  People benefit by these companions, and that benefit is now accepted.  I appreciate their indulgence.  On returning to the document room, she crosses her front legs, and puts her head down across her legs as she nods off.  She is never far from consciousness as her ears are up in a position unusual for her breed, and more akin to that of a Chihuahua.


Legitimacy of snake oil


I return to examine news reports of the time, and with them the inevitable advertisements for medications.  In the nineteenth century, people sold remedies such as snake oil for miraculous cures of common ailments such as joint pain, sleep disturbance, or bowel troubles.  The purveyors would make a show of these sales, and were often part of a traveling carnival.  Scientific data were not required or offered.  Most of us are conditioned to watch such shows from early childhood.  We start by inane entertainments for our parents; they watch us as if what we were doing was entertaining.  They listen carefully and are rapt by our patter because we offer hope for a brighter future.  We continue on with grade school plays depicting heroic events such as the founding of the country, or holiday themed dramas.  In later grades we may produce plays or concerts for our parents.  People love a show or a well-worn tale.  Television shows of the period portrayed models running thru fields no longer concerned about allergies because of the promised chemical protection, men and women racing to the bedroom or nearest available surface to perform bacchanalian sex acts after taking medication guaranteed to produce satisfactory long lasting erections, or obese subjects no longer suffering stomach pains after taking miraculous gastric protectant medications.  Instead of beer and cars, the largest advertising buys for an entertainment for a now banned gladiatorial sport entitled the “Super Bowl” were for medications, health insurance companies, and health care facilities.  In all these scenarios, the ailments were age old, the promises unchanged from past medicine shows, and the cautions were underplayed with either a rapidly read list of concerns at the end of the advertisement, or a small font disclaimer run briefly in view so as to be unreadable.  The FDA or federal drug administration that regulated such messages had abdicated its regulatory function to the hucksters.  These medicine shows are not the stuff of scientific data presentation which often leaves more questions unanswered, cast doubt on hypotheses or methods, and rarely show major breakthroughs or advances.  The way of scientific discovery is often too slow and too complex for pharmaceutical tales, and conclusions reached may not contribute to blockbuster profits.


What was different about these advertisements for medications?  The old time medicine shows were viewed as marginal in society.  By their association with the carnival, the public was aware that claims might be false and misleading.  When commercials were given prime time to be viewed along with other serious and accepted reports, they were given greater legitimacy by society and its legislators.  The caution that people would bring with them to medicine shows was no longer present.  The words of the advertisements were accepted as truth, and often given by actors portrayed as medical practitioners.  These medical “heroes” pierced the veils of trust and legitimacy to hawk their wares in a form of well rewarded promotion of self-interest.


Along with these advertisements were pieces interspersed labeled as “news”.  They are worth examining.  I have viewed stories from what were called the major networks, and have found some common themes.  The people who presented the stories all seemed trustworthy, hale, and beautiful or handsome sorts.  They seemed to mean well, and I suppose that is why they were hired by the networks.  The advertisers surely wanted believable sources of information before their spots.  The medical stories such as the birth of a sheep from a cloned embryo or the risk of heart disease with estrogen replacement therapy in menopausal women showed evidence of one study, viewed from one point of view, and a quick disclaimer at the end basically denying support of the finding.  What was rarely shown?  In most of the stories reviewed there was little discussion of pros and cons, rare glimpses at past literature to give a frame of reference, and rare discussion of the ethical implications of the work.  The strength of the study or the strength of the evidence was rarely disclosed, and the source of funding for the research was rarely mentioned.  These stories were given the limelight that a fire, murder, rape, hurricane, volcanic eruption, or politicians tryst would command.  They were often add-ons as time allowed.


Interspersed with these serious stories and "serious" advertisements were commercials for weight loss drugs, or hair replacement or re-growth.  You might ask how great a concern was this misinformation or poorly researched information.  As time progressed, people were drawn to the television medium for greater proportions of their days.  It apparently was not unusual for an American to watch more than four hours per day.  Often they would watch as a family unit as depicted in the now classic cartoon show about a family named "The Simpsons".  This show set records in terms of length of time broadcasts were shown, generational reach, guest star quality (voices only), and lack of aging of characters.  Unlike the cartoon family whose creators poked fun at American antics and behaviors, most families had little self-reflection or understanding about how this medium and its messages reflected their lifestyles.  Plastic surgery and liposuction ads brought people into surgeon's offices, and kept the surgeons in demand and affluent.  Messages about weight loss programs were heeded, and created an industry based on teaching people how to consume less food for more money.  More time spent drawn to this medium meant less time spent in healthy pursuits.


All the conditions were right for the weakening of the fabric of this society.  To be sure there were those such as EMC calling for change.  They were almost powerless in the face of the marketing machinery that was gradually changing and deteriorating the lifestyles of Americans.  As in the attack of the overzealous parasite, the host was showing signs of weakness.  In this predatory world, others saw opportunity in a weakened country.


I have been at this work for a long time today.  "Is this all?" a college date inquired of a friend after watching the author fall asleep while preparing her a meal, and drinking a bottle of wine.  Sadly, the chef did not miraculously awake and arise.  Gracie, and I must head for home, and begin again tomorrow.  While serious about this analysis, I am also serious about sleep, and love the comfort of home, and a warm bed.  From the library to home is a walk of two miles.  It will do us well to brave the cool air, and stretch our legs.  What should we eat tonight?  We had pasta with sauce last night, and our bedtime popcorn.  Perhaps tonight will hold other delights.  I am a reactive cook, and must look into the refrigerator for possibilities.  Given half a green pepper, some butter, a sausage, and cheese, there may be an omelet in our future.  While these thoughts simmer, the light rail goes whooshing past.  The automobile is less often seen today as fuel has reached intolerable prices for most.  The markets for fossil fuel is global, and the Chinese now command the lion’s share.  The scooter is everywhere much as it was in Italy in the last century.  No Roman holiday was complete without a life-risking street-crossing.  These thoughts bring back the memory of life with great grandparents.  I often stopped at their house on the way from school, or stayed there if the folks were engaged elsewhere.  The street in front of their house had recently been cleared of light rail as the automobile was becoming more and more common.  In one hundred years the we have come full circle.


Asses and Elbows


Great Grandfather (Grampa or GGP) and Great Grandmother (Gramma or GG) would freely share their worldly wisdom with those who would listen.  They told enthusiastic stories about the past, and their lives and travels.  In fact, their health problems were the reason I focused on medicine as a profession.  "Asses or elbows”" was a regular refrain at their house.  “Don’t get old, son.”  “When I was your age we didn’t have cars, and worked from the time the sun came up.  If we wanted to go somewhere, we walked.  I spoke seven languages by age ten in order to trade with Poles, Austrians, Ukrainians, Russians, or Germans”.  GGP never took multivitamins, but he did take a nip from the whiskey bottle nestled under the winter coats on the front closet floor as he came in from the cold.   He would put his finger to his lips in a gesture meaning “hush, don’t tell GG!”

To this day I will never forget the day that GG stopped me on the way out to a dance, and thought I should be more aware that grandfather lay deathly sick with a heart attack.  I don’t remember the dance, but I remember that GP lay in the hospital bed reading from a large stack of books for the six weeks that it took before he was deemed better, and ready to come home.  He came home a changed man.  He no longer smoked, he ate less, and he walked to work and back most days.  Gone forever was the “pot belly”.  Before it had been a long time since he had walked a mile, but now he was doing it twice a day.

When GG got sick with ovarian cancer, she also got depressed.  There was little anyone could do for her, and she was in pain most of the time.  Eventually she was bed-bound, and died with little help from any of us.  This was before the hospice movement, and people seemed to have no idea of how to care for her in a loving way.  She was a proud woman, one of the first to graduate from high school in our town, and an early advocate of women’s rights and liberation.  She deplored her condition, and was ashamed of having others care for her bodily needs.  She must have died feeling alone in the world.

GGP kept on going despite all these troubles.  At one point in his seventh decade, and after fifty plus years of marriage to GG, he told us he did not think he could live with her anymore.  These moments of marital frustration passed quickly, and soon he was quietly and joyfully smoking another Cuban cigar.  He used the trunk of his black Lincoln Continental (the one with the “suicide doors”) as a humidor for his Cuban cigars.  He smoked about ten a day all his life, and enjoyed watching staged wrestling as the smoke filled his living room (though he slept through most of the histrionics).  His idea of working out was putting a vibrating belt around his middle, and jiggling for five to ten minutes a day.  He did get into his car every day to visit with friends stopping four or five times for short walks into stores or restaurants.  He ate with relish, told stories to his friends, and came back home for a snooze.  If he had problems with his health, we were unaware.  He died late in life, well into his nineties.  He was driving a Cadillac with springs at each corner to “feel” the curbs which he was unable to see through his Coke bottle glasses.


The Reactive Cook


The aforementioned ingredients are now assembled, and ready to be fried.  The eggs are scanned, and found free of harmful bacteria and viruses.  The aroma of vegetables and scrambled eggs comes from the countertop to nose.  Oregano, black pepper, and sea salt are added.  Perfecto!  Gracie reminds of her portion as she takes up her attentive sitting position next to the table leg.  We are bachelors this week as the wife is visiting her parents, and should be calling soon.  The holographic phone is on, and when she rings in I must leave you briefly.

Some foods used to raise concerns about stomach upset.  More often a restaurant meal was suspect in year’s past as Pasteur’s influence took a few hundred years to become pervasive and Koch’s postulates were complex and beyond consideration of most.  What was so difficult in understanding that infection was carried from the source on the preparer or examiner’s hands?  Why was it so difficult to get these folks to wash their hands?  Was contagion an act of neglect or will?  What was so hard in covering the mouth of the cougher?  What was so demanding in refrigerating foods?  Now preparers and examiners are rewarded for their diligence, and given other work if they fail to meet standards.  Once bacterial, viral, and toxin screening became mandatory in food preparation, we are no longer as concerned about contaminants.  Our concern remains linked to preparers and processes.  In fact, as the science has grown, we are now aware of the ingredients of all food with the use of home and portable biologic scanners.  Most never enjoyed time spent hugging the “porcelain goddess” or the days confined to home to be close to porcelain friends.  Despite the new plastics that have replaced the goddess, many cling to the old style.  Some are unable to forget the cool feeling, the clear lettering denoting the maker, black on white, and the relief found after this near death experience of bowl hugging.  For those who have never welcomed death as a reprieve from this torture, I wish you well, and hope this experience is only of literary interest.


The beeps indicate that the wife is ringing in, and I will leave you briefly.  We never talk long as neither of us are comfortable with the omnipresent holographic image despite the lack of delay, and highly pixilated images.


All is well in Texas, and the news was assorted.  Nieces planning weddings and college visits, nephews winning yo-yo tournaments and becoming mayors of simulated cities, grandchildren sleeping through the night, days sunny, and everyone enjoying good health.  It is heartening to hear of loved ones, and more poignant than fiction.  I was visiting down there a month before, and enjoyed the heat, good weather, and family love.


Don Quixote


Gracie gets her portion, and cleans the plate.  The dishes are in the washer.  I would like to get some rest but will instead sit on the couch, and read Tolstoy or Cervantes.  I prefer long dead authors, and read all they have written.  I often use juried prizes such as the Nobel or Pulitzer to guide literature choices, and am rarely disappointed.  The books are worth returning to.  I never tire of Cervantes’ stories, the Spanish knight and his Sancho roaming the countryside in search of adventures.  These interludes also lead to sleep although when asked the response is that I am just resting weary eyes.  As one ages, napping becomes a matter of pride rather than denial.  What is the knight up to?  Has he seen some knave or damsel in distress or has he had another of his wonderful delusions?  Too bad that Don Quixote didn’t wander into a twentieth century hospital, and run rampant with his lance, steed, and squire; a preference would be for Cervantes to turn his wit to health care dilemmas!


What if he had?  What if he had promised his noble Dulcinea the head of the knave or other low borne culprit who would not yield to his mighty lance and misinterpretation?  One might imagine the damage that he would do if Sancho was pushing him into a paper chart-room imagining it filled with demons.  Of course the hospital staff and administration would quickly diagnose his malady, and cause him a drug-induced behavioral change similar to the "care” the hero received in “Man facing southeast or Hombre mirando al sudeste (1986)”.  On awakening the heroic knight would find himself bound with leather and steel, and crying out for his squire’s assistance.  After a few more injections he would no longer cry out, but only lie in his filth, and gaze out onto his few disordered thought visions.


Perhaps I should read something less heroic.  Murikami, Gao Xingjiang, Mo Yan, Joyce, and Saramago come to mind.  Their discussions and stories are more surreal, and their lead characters more ordinary.  Before I launch into this pattern of thought, another overtakes me.  It is a wonder that I have ever published histories with the wandering train of thought I contend with.  A letter to the wife is just what I need to sort out these thought strings which leave me so tangled.


Tangled strings


I need to write you.  This archaic form allows the dominant left hand to connect directly to the mind, and express thoughts more clearly.  Your absence has made me feel lonely, sad, and incomplete.  We are such independent people, each capable of important work, each lost in our own worlds.  This week in your absence I have worked on the history of medicine in the last one hundred years, and have a much better understanding of the past.  I have tried to fill the emptiness of not being with you by reading and other artistic diversions but they are a pale and distant distraction compared with your presence, our dialogue, and the sense of peace I feel when you are near.

Had you been here, we might have discussed the abuses of power, the inertia, the mal-distribution of wealth, and the machinations of the people that led astray health care for so long.  How wasteful these times were.  How painful to be caught in this senseless time, and desperately need excellent medical care.  Many people must have suffered greatly, and not understood the madness of the neglect they felt.  But this work needs a muse, and you are that muse.  I have tried to consult Saramago and Proust, historic mentors and literary experts.  They whisper in my ear that people give far more to their kings and elected officials than their government ever gives back.  In fact, with and without the constant attention and sacrifice of the people, the government abuses, and its abuses are more outrageous.  But fiction has left me little guidance to deal with the abuses of trust and power seen in the last hundred years of American medicine.  Historians documented social transformations in medical care, and economists showed the need to re-define the process but they were largely ignored.  The complete lack of self-awareness, the ignorance guided by pride, the delusional vision, the sinful greed, and the resulting painful care delivery would have been difficult to imagine.  It is with our dialogue that I am able to piece together the letters, notes, chart events, newspaper articles, and other media snippets that clarify the past.  It is with our dialogue that I realize that this is a real account terror and horror fiction writers never have imagined.  In fact, the surrealistic vision would be unprepared for the Guernica (Pablo Picasso) that was medical care

In the conscious mind I understand the enormity of our marital undertaking.  In our lives we have so many others that make life worth living.  I have tried to do one good thing each day but come up short more often than I care to.  Who would we be if we did not have our heritage, our children, our elders and teachers, our parents, our siblings, and our friends? Would life be anywhere near as complete, and richly complex if we devoted most of our attentions to each other while sacrificing time with others?  How do we balance the competing interests?  How do we know our own interests when reactions to the interests of others compete, no matter how close?  I want some of your attention, nurturing, and care but many others need you and your gifts as well.  Perhaps this feeling of never having quite enough is the best aspiration.  Perhaps the oppression of proximity prevents the joy of expectation, and wonder of appreciation and gratitude.

I would not trade a moment of watching a new grandbaby eating rice cereal for the first time; watching along with daughter and eldest granddaughter for the expected movement of the tiny tongue as it pushes the viscous material around the mouth and back out.  To watch the moment of unexpected swallowing, and surprise at the result is indescribable.  To be there with one little girl so the other has the complete and undivided attention of her mother.  A day spent playing catch or soccer, or making new delicious concoctions with the young adventurous chefs is a unique experience, exhausting but satisfying.  Sometimes we must part to be a part of these events.  These wonders are best when shared but simultaneous sharing is not always possible.  How much more we have done in life by allowing freedom of movement, and indulgence of and fulfillment of filial yearnings. 

How much time should we save for ourselves, and how much should we devote to others?  How much to others and how much to our families?  In the hierarchy of wants and needs, our relationship has allowed growth and fulfillment.  Rather than going in lock step along the path, we have performed solo but come together to review and appreciate the art.  I consider life-art, working through the problems of parents or taking parents out for meals and shopping when they no longer are able to achieve these goals independently.  Envision taking your father out of his confinement for a few hours, first with a simple lunch and then to a store where he is able to buy packages such as detergent or a bag of bird seed that would be too heavy for him to carry alone.   Envision taking your mother from bed to chair to converse upright rather than supine.  A life would be well spent if devoted to these pursuits alone, but how much richer with children and grandchildren.  I look forward to sharing these joys and memories with you.

What a wonderful age we live in.  Cooking is only limited by imagination.  Endless delightful flavors, textures, and scents come to mind.  Artichokes in melted butter, avocados with chipotle salsa, and herring in red wine sauce compete with flavored or plain yogurts, cheeses from all over the world soft and hardened, and wines from so many soils, waters, and climates.  Wines are wonderful today.  They all start well with forward fruit, reverberate with subtle hints like oak or vanilla, and finish in a complex medley of fruit and minerals.  Some bottles are better but most are good.  These little companions come from every region of this country, and travel from every wine producing region in the world to rest on our table.  There is no place today for poorly produced wine.

Travel both real and holographic is exciting and full of adventure.  What will be beyond the turn?  What architectural style has been preserved, and what art has been left for us to marvel at?  What new foods and wines have matured here?  What challenges will exhaust our bodies, and bring refreshing sleep? 

So let us be together whenever we are able.  Let us live fully, and freely.  Let us know the joy of a young one pulling our hair or ears with their beautifully articulated tiny fingers.  Let us play games, build structures, race cars on toy tracks, draw from rich phantasies, and make unusual brews fresh from garden plants. 

I miss you, I love you, and I long to be together with you.  Now I close and will sleep with prayers and visions of you.

With all my love.



Before sleep, I am interested in viewing a hologram.  Before me are many titles.  Akira Kurasawa is the one who draws me in tonight.  Rashomon (1950) seen again after so many viewings.  When will the truth be revealed?  Is truth absolute or a complex blend of countless perceptions and distilled reality?  Is it true that of all animals, humans are the only to lie?  Do we lie because the truth is so complex, do we lie to protect ourselves from another reality, or do we lie to prevent harm or bring harm to others?


Reminder to self; write to the children.  I have the urge to share life’s stories with them.  They are all doing well, that is to say they are all independent and facing life on their own terms, but a father longs to plumb the depths.  Worry is also a parental occupation that shortens the hours of otherwise long days, and lengthens the nights with eyes wide open.  We are at the age of weddings, births, and passings.  Perhaps these events are for all ages but at some they are more poignant.


An electronic letter to my son is in order before the holograph.

Thanks for the wonderful journaling from travel in Hungary, Bulgaria, Romania, and Turkey.  We miss you and hope the trip is a great one.  Sounds good thus far.  Wish we were with you.

Have been having adventures as well.  Had a great time in Connecticut with R, J, So, Char, and Shaena.  R is so good with that brood, and they are all fun to be with.  So is becoming an interesting independent young lady who likes to play library, Cinderella, soccer club player, and big sister all in the same day.  Char is all smiles and laughs when not burping up formula.  J seems to be handling the family life well.  The house is well used, and nicely decorated.

We went to the Green mountains of Vermont for a weekend.  Had maple syrup, maple candy, blueberry pancakes, and walks in the snowy woods.  Kept a fire going for the weekend.  Watched as the Chicago Bears football team became super bowl hopefuls along with the Indianapolis Colts.

Flew back from LaGuardia to Chicago, and went to grandparents.  Spent the week working on the condo.  Also took grandpa to lunch and shopping, and went out with G as well.  Got the garage door opener installed, a dumpster brought in for the old kitchen cabinets, a new IKEA kitchen installed (mostly M as I was having back pains), and the last wood floor installed in the guest room.  The place is looking good, and should be ready for patio living this spring and summer.

Took the bike to B’s Deerfield Cyclery for a tune up.  Will pick it up next visit.  Started working out at the nearby North Shore Senior Center, and got a library card at the Northfield library.  Took out a Saramago (Seeing) and McCarthy (All the Pretty Horses) as well as a DVD, Howard's End.  Saramago keeps satirizing governments, in this case a democracy.

Will work on bills and retirement related matters this week.  Am writing some and need to write more.  Be well and enjoy your travels.  Gave your new music to Grandpa and L.  Congratulations!


Back to the holograph of Rashomon.  Tishiro Mafune is in a classic rage with broad brush facial expressions and dramatic posturing.  He is not the last angry man but plays one of the best.  Listening to all the renditions of the tale is heightened by his versions of truth.  I remember being angry, and once spent part of each day enraged.  Rarely do I feel that way now.  Never have I felt a murderous blind rage, but that burning spiraling passion reminds me of times passed.  When I was young I remember waiting for a school bus in the winter cold.  As I was on the curb standing in a foot of snow the bus seemed to be passing me by.  I swung out in a blind rage, and hit the side of the bus with all my might.  The bus driver stopped, and yelled something at me.  I do not remember what he said but I do remember the pain I felt in the right hand.  Later I found that I had broken a bone with that wild swing.  I also have a vision of playing basketball with friends, and swinging elbows wildly to be free of the grasp of another.  At the time I was unaware of hurting a best friend in the mêlée.

Now I marvel at anger that others show evidence of.  Anger at being ignored, anger at conversation and remarks of others, anger at lack of attention all smolder and fester.  These angers now seem like indulgences, feelings that are nurtured, given special meaning, and given new life as affronts never intended or intended to enrage to see the reaction of the recipient.  If one is receptive, one will find offence.  It is difficult to give up a reaction one has nurtured over a lifetime.  I am told that some marital partners never are willing to give up such rage, and feel it long after the perceived affront.


In Rashomon, the wife, the medium, the thief, the murdered husband, and the moderator have all had their chance to tell the story.  I appreciate these thought trails or clips of pictures that reveal a concept or a story in a unique way.  They seem to have direct link to brain chemistry, and unlock a flood of chemicals which cause me to feel sad, angry, excited, affirmed, or surrounded by hate or love.  These holograms are much more accessible than the written word, and bring the arts to more people than dance, painting, sculpture, architecture, classic music, and opera.  Stories like those portrayed in Casablanca (1942) or Tsotsi (2006) are so powerful when paired with a sound track, they seem to enter the mind directly. 


Five percent of all medical knowledge

In bed I feel a severe pain in the left pelvis.  It has prevented me from putting on socks, pants, or moving anywhere quickly.  The anti-inflammatory medicine ibuprofen has not helped.  Two weeks of rest has not helped.  The pain persists.  I am reminded of a wise professor years ago who thought we knew five percent of all we might know in the science of medicine.  Much was yet to be revealed in the care of ailments. 

In a dream I enter the clinic, and am greeted by the scanner that reads information from a card presented to it.  The door opens, my name is called, and a room is assigned which I slowly walk towards.  The android takes the card, reads the previous information, and takes the vital signs as well as current symptom history.

The doctor appears on the monitor, and gets additional information.  He adds it to the information previously given.  A differential diagnosis is developed by algorithm, and reviewed by the staff.  They confer, and develop a plan of exams and tests to clarify the problem.  I am aware of all the positive and negative aspects of these tests including any personal costs and alternatives.  Another doctor enters the examination room and completes any necessary physical examinations to further narrow down the possible causes of the pain, and gives the nurse a list of necessary laboratory tests, and other tests and therapy to schedule.  From the initial finger scan on entry, the blood examination is completed, and a body scan is performed and read by computer simultaneously.

Torn muscles are found which are necessary to move the left hip, and needed to be able to walk.  The tear is partial so I continue mobile but in pain.  Other tests are pending, and a trial of a more powerful anti-inflammatory medicine is prescribed which will be picked up on the way home.  A follow up with a call in one week is scheduled but all results are received through the week on electronic mail.

The results have been transmitted to the patient, and to the exercise facility.  The trainer there is aware of the injury at the next visit, and has laid out a plan of exercise for rehabilitation.  In the visits three or four times a week a routine is developed to maintain strength and mobility in non-affected areas, and work to strengthen the hip and back affected.  The best part of the visits is the session in the steam room after the work-out.  All the aches are carried off with the steam, and breathing is deep and easy. 

A masked face surgeon lurks in the background, and is anxious to get me to consent to surgery, anxious to immobilize me, and anxious to put five pounds of metal screws and plates into my back.  The threat posed by the knife-wielding apparition is recognized, and carefully avoided.  If his services are needed, the doctor will counsel in that direction.  Since surgeons are no longer paid by operations performed; now they are team members with particular skills and robotic assistants, and they await the team conference and ultimate shared decision.  The doctor has no incentive to guide in any therapeutic direction other than to restore good health.  The patient believes and trusts his judgment, and uses all resources to better understand his advice.  I try to be well informed in these matters.  Information needed on the injury is brought to mind, and reviewed for better understanding. 


On awakening I feel a chill.  The thermostat was set at a low temperature.  I must crawl into bed, and pull up the warm oversize down comforter.  Warming up a marital bed with one partner is difficult, and reminds me of loneliness and absence.  In the morning, my wife will call, and the day will be previewed.  For now, I undress, say prayers of thanks, and climb into the bed.


Yesterday seemed to never end.  But the earth has revolved once more on its axis, and I welcome the new day and the sun.  It is warm now in the bed, and I hesitate to get up into the cool morning air.  The task at hand calls, and all of the materials await at the library.  The chore is made easier by a two pronged approach.  Thus far I have tried to understand the changes we are now aware of, starting with the early case chronology. 

At the same time, I am working backwards from the present.  The present is so well known to the audience, and so well accepted that it is difficult to take them back. 

I review dreams of the prior night, and find no surprises.  This morning I will set the baseline a picture of care in 2050 and begin to work backwards.  Before I get too lost in thought, oatmeal and raisins along with green tea are prepared and consumed, and Gracie demands her walk, and reminds her human of the meaning and importance of health.


Mona Lisa

We walk along the lake front, past the beaches and short icy barriers.  Beyond is a far reaching blue green expanse covered by choppy waves and white caps.  Periodically Gracie tugs, and we stop as she inventories the scents from the night before.  Soon we arrive at the library, and begin another day of work. 

The table is clean and materials stacked nicely.  The recording tools are as I left them, and patiently awaiting additions or corrections.  To this mind the greatest passion in life is editing.  Certainly love, sex, eating, drinking, and getting and spending have their place, but editing is a joy never fully satisfied.  Each day, I look critically on the work of previous days, and feel the urge to change a word, a phrase, or re-order paragraphs.  Those complacent or full of the other passions should give editing a try.  No work is so perfect it cannot be changed.  It is said that Leonardo da Vinci kept the Mona Lisa with him on his travels, and never completed the work.  He would add a brush stroke here, change a color or shade there, but died with the work incomplete in his eyes. 

While most of us do not have the good fortune, skill, or ability to paint the Mona Lisa, we all create from the moment of our births.  There are joys and disappointments in these creations.  Some creations are for self-fulfillment, some are for commercial approval, and some are for artistic approval.  Whatever the audience, the need to produce and create is strong in some people.  Forgive the storyteller who gets lost in the process.  How wonderful the result when the time spent in corrections helps others to identify, learn, or enjoy the labor.  Some authors come in and out of their reality and their fiction.  Is there any non-fiction?  The central theme of Rashomon is raised again.  For those who have not seen this magnificent story, it is worth your spouse’s derision or somnolence.  The term “artsy-fartsy” comes to mind but brave on through the torrent of sarcasm to the golden core of realism and the quest for truth.

Thoughts wander again.  The well-disciplined mind would focus on the work at hand, and push all errant thoughts from the fore.  Mine lacks such discipline, and follows paths like molten lava.  Let’s get back to the work at hand. 



Mr. B. 2048


The record, 20481130B. (the record is recalled from computer memory with appropriate passwords and security clearance).  It documents care in the year 2048, and is comparable to others on file.  It deals with a man who video conferenced to the care control center from his home.



Chief concern

Chest pain


History of present illness

Mr. B. had been at home with his family.  He and his wife had discussed his work situation which was stressful.  Over the past few weeks he had felt pains in his chest that were vague and short lasting.  His wife brought him antacid tablets but he got no relief.  He tried to ignore the pains in hopes that they would go away.  The last few days the pains had increased in duration and frequency, and tonight the pain persisted unabated.  He described the pain as a tightness in his left chest, and also felt pain in his neck and left arm.  He was no longer able to wish the pain away as muscular strain or deny that the situation was not serious.  He felt some nausea and a slight fever as well.  He was exhausted and as weak as he had ever felt.  He had never before had problems like this but his mother died of a heart attack in her nineties.  His blood pressure was high and poorly controlled as he often forgot to take his medicine.  He was overweight and had been told to watch his sugar.  He had smoked more than one package of cigarettes per day since his teenage years.


Past Medical History

Medications-he did not remember the blood pressure medicine and had not refilled it, because of cost and lack of effect.

Allergies-none known


Injuries- “bad knees”

Lifestyle-smoked and overate regularly, and did not exercise. 




Social History

Mr. B. is a fifty-six-year-old accountant with many concerns and much suffering.  He had been married to Mrs. B for thirty-three “marvelous” years as he might say to friends (after the second glass of wine).   The couple had three children, all gifted and bright, and all teenagers at the time of this writing. College and the costs of college educations were concerns for Mr. B. as he wanted to give his children a better start in life that he had.  Just thinking these thoughts put a hologram of B.’s father in mind; his father would say that the greatest investment he ever made was in the education of his children. (That was before B.’s brother took a second wife without letting her know she was not his only “love”).  B.’s father began to wonder if he should have spent more money on counseling for his children at earlier ages.  


Work was not going well for Mr. B..  He worked in a large corporation, one of the Fortune 50. Jobs were going overseas, going to younger associates, and “lost” in re-organizations and “synergies” of mergers.  Next merger might be his last as the company tried to “right-size”.  For this reason, he had been visiting with friends who work in the city, and explored what the market for his skills might be.  “Never hurts to look” became his mantra.  The stability of days gone by was a fond memory for some, but B. had come to look at retention at work as a cake walk.  Someone would be standing when the music stopped with no available chair, and they would leave the game to others.  Skills were important, relationships with co-workers were important, but sometimes no chairs were left, and it was time to leave.  B. was grateful for his time, and appreciative of years gone by.  Still it hurt to leave, and brought considerable disappointment and sadness.  He had tried in his way to make improvements, and help the company through its mission and values. And in his mind he heard “one may lose many times but try again to improve your performance; losers are those who quit trying” and “if you never swing, you never hit the ball”.   He wished his mind would talk to him less. *


*editor’s note (this note is typical of current information as the patient is urged to disclose completely, and in no way is information used against him in future scenarios or determining insurance coverage)

Review of systems


Skin-acne in youth, some dryness

Head, eyes, ears, nose, and throat (HEENT)-no complaints


Chest-above, short of breath with one flight of stairs climbed


Pelvis-no complaints although no sex for a long time

Extremities-leg pain on walking more than one block

Central nervous system-anxious and trouble sleeping


Physical examination

Blood Pressure 210/120 Pulse 100/min with irregular beats Respirations       25/min Temperature 100 degrees F Weight 248 pounds   Height 5’10” (information gathered by home transducers, and transmitted at the time of the video conference; the finding to follow also come from video, physiologic, ultrasound, or audio transmitters.  When the history and vital signs came across to the care center, a module was dispatched to pick up Mr. B, and bring him into the care center for further testing).


Skin-acne rosacea over the nose and cheeks; marked cracking and fissuring of the facial and neck skin

HEENT-pharyngeal leukoplakia; normal thyroid without nodules

Heart-normal sounds without murmurs, rubs, or gallops

Lungs-clear to auscultation and percussion

Gastrointestinal-normal bowel sounds; no bruits

Extremities and Back-normal range of motion but mild weakness noted

Genitourinary-normal male

Central nervous system-all intact reflexes and cranial nerve functions


The remainder of the exam was performed at the neighborhood care center.  Mr. B. arrived at the center within ten minutes of his call for the completion of evaluation and start of therapy.  A complete team of physicians, nutritionists, exercise physiologists, and nurses evaluated his information, and made the recommendation and care plan after reviewing computer generated outcomes models for the best possible care.


Cardiogram and radiologic evaluation-ST elevations in the anterior precordium suggesting recent anterior myocardial damage, with corresponding calcifications and chemical evidence of plaque and scarring.


Cardiac panel-evidence of recent myocardial damage


Remainder of laboratory tests normal accept for mild proteinuria



  1. Acute myocardial infarction due to atherosclerotic vascular change and hypertension
  2. Hypertension
  3. Cardiac risks including smoking, work stress, family history of heart disease, and obesity
  4. Acne rosacea
  5. Pharyngeal leukoplakia most likely related to smoking




  1. Immediate cardiac auto-angioplasty by inhaled enzymatic clot and thrombus degraders
  2. Overnight observation and heart rhythm stabilization
  3. Lifestyle interventions by social contract to be signed by patient, employer’s representative, and family.  These include smoking cessation, stress reduction with behavioral therapy, weight reduction, and blood pressure control.
  4. Care follow up with weekly videoconference and information transmission.




Clinical course summary

Mr. B. stopped smoking with the highly effective medications and nurse care coordinator contacts.  He also managed his weight with a resulting seventy-five-pound loss.  His exercise regimen was followed along with daily walks to work.  Behavioral counseling and group therapy have been highly effective in helping him with stress and life cycle concerns.  He now enjoys his life, family, and work, and has managed his stress well.  His preclinical course illustrates that despite advances, people do not always comply with prevention guidelines or establish safe baseline health data.  Many people need to focus on an event before working on their health.


Artist P and Nine lifetimes


Time for a break.  Gracie needs a walk, and her caregiver needs a snack.  On the way to the food machines, we call our friend, P.  He is drawing with ink and pen at a local bakery, and will spend his day off there.  The work is displayed on the screen, and is disturbing in color and object but probably relieving some tension that P felt.  Some kind of ectoplasmic creatures are escaping from the paper surface, and cavorting with one another in highly erotic positions.  Identifiable body fluids are escaping in well composed and colored globs.  Organized chaos reigns in the composition.  P. controls the chaos, and limits it to 20 by 28 cm grid.

When we were children, P. never pursued music or art.  He seemed to feel that he would take over his family’s business distributing newspapers.  Now of course newspaper is a historic curiosity, and information is ubiquitous.  It was assumed he would be a good kind man like his father who pushed his own needs below the needs of family, and deferred to his brothers every day in business.  As P has aged, he has devoted himself to art, and to the subconscious flow of ideas and visions from his fertile mind.  He is a good kind man, and his own light shines brighter each day.

He has played his Shakahachi in between fares in his for-hire transporter, and written poetry or Senryu for as long as I remember.  Last time we talked he was metaphorically “in a well” with one of Murakami’s characters, isolated from society.  Usually he is very content to engage his fares in conversation, and develop theories about why the Bears have not won a super bowl since late in the last century.  Today or once a week he sets aside to allow demons in his brain to manifest themselves on paper, and teach him about his subconscious mind.  We talk once or twice a week.  Sometimes I drop in to see his work, and get his unique perspective.  We have known each other for more than sixty-five years, and the shared history allows us common idioms, ancestors, and memories. 

Does a person become wise in one lifetime?  If one lives nine lifetimes perhaps they will acquire the necessary wisdom to understand life more completely.  As most of us are limited to a lifetime, the wisdom of friends, family, and artists who share their visions are needed to help us lessen our struggles, heighten our senses, and reduce our frustrations.  We understand life a little more, and we gain greater insight when we ask friends, associates, and authors to enlighten us, and share their visions.  These views are given to exaggeration, hyperbole, and blindness at times, and we ultimately must discern a true path.

Gracie tugs on the leash and we sign off, and head out before satisfying bodily hunger.  I have remembered long underwear today, and am much more comfortable in the weather.  The wind has less effect as long as one keeps warm under layers of heat retaining fabrics.  Bundled, it is difficult to see the dog near my left leg.   I feel her tug on the leash when the need arises for her to relieve herself, investigate another animal’s scent, or protect the flank from others.  It has snowed again, and the surface is white and dry.  The author is not a follower of clothing fashions, and has been the subject of derision of some people labeled the “fashion police” all through life.  However, in cold weather, one is supremely comfortable in a hat, scarf, heavy coat, long underwear, and springs under the shoes.  Little ice has formed so the walk is without hazard, and soon I am back to choosing between sweet and gooey or crunchy and salty.

All the snacks look good, and seem to be calling but there are favorites, and today crunchy and salty wins out.  The hazardous food tax adds to the cost of the snack, but it is worth every yuan at times like this.  The cold weather requires a greater energy store, and every puff of steam that leaves my balaclava for the frigid air, allows greater caloric freedom on the intake side.




Yes, Yuan.  As you might imagine, most of the supplies, equipment, and analytic capability were provided to the physician-hospital complex from China.  In addition, many practicing US physicians were Chinese citizens trained in the US.  As long as the return on investments was good in the US, China allowed the balance of trade so that goods flowed into the US, and credit flowed to the Chinese government.  This situation describes what happened from the late twentieth century to the first quarter of the twenty first.  When greater yields for investments became available in Europe and South America, the Chinese gradually liquidated many US assets, and took the cash elsewhere.  Doctors trained here returned to China, and those who protested were soon given reason to worry about the safety of their families in China.  This created a panic in the US as gold bullion and physicians were in short supply, and the quantities of gold required to satisfy the Chinese were simply not available.  Our debt had grown to a multiple of eight compared to our hard assets.  We were completely overextended.


The story of foreign influence in US politics (any nation’s politics for that matter) is well known, and is related to the situation of reduced productivity, un-skilled labor, rampant drug use, imbalance of mind and body, and imbalance of trade.  The transition in medicine swept out the previous chaotic practices with modern clinics, modern tools, and a predominance of foreign workers.  Since the US populace had been reduced to an over-eating, drug abused, needy lot primarily focused on their entertainment, they were ill prepared to take the skilled positions needed by the new health care system. 


With foreign ownership came foreign direction.  Puppet governments yielded control of medical care, transportation, and energy production.  In the case of medical care, the transition was a boon to the populace.  Like Wim Wender’s angels in Wings of Desire or Der Himmel uber Berlin, 1987 the Chinese observed and listened to all sides.  They had gone through their own revolution in health care early in the century, and the government had once again taken control of the system.  Eventually they quietly and thoughtfully created a national system of health care similar to the Canadian or British health care systems.  Their goals were improving quality, reducing costs, caring for all people who needed care, and using twenty first century technology wisely.  Of course they wanted a return on their huge investments as well.  When they acquired most US companies, they were obsessed with reducing costs.  Since product costs in the US were often a result of high health care costs, by lowering the cost of care, they were able to once again find a market for US products.  Most Americans never saw this take-over coming.  They had not learned from previous raids on US assets by Europeans, Japanese, and Middle Eastern groups.  They thought that US corporations were run by US interests.


Center of excellence and value


As this holographic work will be scored, at this point some peppy symphonic piece such as Ravel’s Bolero may start to introduce the section.  Excellence in Medical Care, the organization founded by Mrs. A. had continued to be a voice in the storm.  Now their work was brought to the front of the stage.  The Chinese had their own experiments with quality of care earlier on, and had allowed villagers to move physicians out of their health plans if they over-prescribed expensive medications, or used un-necessary diagnostic tests.  They had created public displays for these score cards, and eventually reformed most physicians or voted them out of their plans.  In the Chinese system, people conformed to the national plan or faced governmental “corrections”.

EMC had developed score cards for hospitals and physicians based on widely accepted standards worked out by the hospitals, consumer groups, physician groups, insurers, governmental bodies, and other interested parties.  They advocated a change in the reimbursement system to reward excellence in care rather than quantity of care or medication therapy.  This plan and process fit well with the system the Chinese had developed, and was a culturally sensitive acceptable approach.  Consumer bodies were developed in health care regions throughout the country.  These bodies reviewed EMC reports, and suggested reform to providers.  Those who did not change their pattern were taken off lists of covered or network providers.  The system was far from perfect but allowed for improvements, and quality improvement projects.  EMC became a governmental body, and headed these quality improvement projects.

The government formed a national body to review new drugs and technologies.  This group was a non-biased professional body overseen by EMC.  Their deliberations led to coverage decisions for the health plan, and their recommendations were put into effect by a coding and reimbursement sub group.  These decisions were published for anyone to review and contest.  As technology is constantly changing, new information was often brought to the fore, and coverage decisions changed over time.  Appeals bodies met in each region to review the application of these determinations for coverage of care.

To be sure there was dissent with these plans, but so strong was the Chinese influence and ownership of the assets of care that most objections were quieted.  Chinese care providers were returned to the states, and represented the largest percentage of providers by ethnic group.  Nurse practitioners and physician’s assistants were trained in great numbers so that the ratio of physician to practitioner was 1:4.  The new administrators advocated and were successful in removing redundant health care systems such as the Veteran’s Administration and Medicare, and focused on a single health care system.  Providers were generally controlled by the mainland Chinese government, and formed a core who understood the consequences of serious protest against process reform.

As Bolero continues to rise in volume and energy on the audio track, the picture of a health care system fills the view.  For the first time in four hundred years in America, people were more likely to seek care when they needed it, the care was available to all who sought it, mistakes in care were continually investigated and diminished, and the providers were rewarded for the excellence of their care delivery.

Pedantic egotistical providers unable to control their anger or urges were gradually marginalized or left medical practice.  The ratio of men to women reversed, and hours of practice became more shift oriented.  The doctor once again became more like a teacher or trusted advisor, and less like a greedy business person focused on profit and opportunity.


As a friend has pointed out, when the gluteal region is sore, the mind is less receptive.  Time to get up and stretch.  The venerable Museum of Science and Industry is near-by as are historic homes by the architect, Frank Lloyd Wright and his contemporaries.  Gracie is stretching her legs as she does before our walks, and it is time to dress warmly and venture out.  Outside the air is brisk, and the leash is taut.  We walk past the classical forms supported by beautiful columns of marble.  The ceiling is high with skylights atop the roofs.  The copper roofing is oxidized to a green color, and is a stark contrast to the Wright houses we pass with their short stature, and ability to blend with the surrounding landscape.  The sine wave well describes the chronologic change in architecture as well as many other fields.  It leaves the base line or classic, advances with new trends, retreats to the classic, descends to new lows, and returns to the base line in a never ending cycle.

The lake is rough today with white capped waves standing out in a field of green water.  The water's edge is frozen, and has moved out near the breakwater. 

As the breeze is near gale force, we retreat to the more protected Hyde Park streets to finish our stroll.  Many of the grand old buildings have been preserved.  America is taking on a European appearance, and aging well. 

An old tale comes to mind as I think of the application of greater wisdom and prudence to necessary change.  In this very area lived an Indian tribe who for years had searched their villages once each year for the most beautiful maiden in the area.  This maiden was prepared in the finest clothing, and fed the best portions by the tribal elders.  On the day of the yearly festival celebrating the river which fed their fields, the maiden was given to the river as a bride.  Each year this sacrifice was made in order to assure the water for crops and to ward off flooding of the fields.  The parents of these maidens were sad at the loss of their daughters, and sent a representative to the chief who had recently consolidated the tribes. 

The new leader was a fierce warrior, but also a wise man and a careful planner.  He had grown up in the belief that prayer and wisdom pleased the gods most, and that human sacrifice was painful and of no value.  However, in order to affect change, he was willing to do what needed to be done.  He and his retinue traveled to the river people at the time of the festival.  They met with the tribal council, and their advisors. Through careful study the group understood the sacrifice and the practitioners.  After days of meetings with the elders of the tribe, the day of the festival finally arrived.  When the time came for the maiden to be given to the river, the leader stood.  He asked that the leader of the tribal council be given to the river first to carry a message to the river god for immediate reply.  The braves gave over the council chief, and he was given to the river god.  When he did not re-appear, the leader offered the next in command to the hungry spirit.  When he did not re-appear with the answer from the river god, another elder was "sent".  This continued and the council diminished until a wise elder stood as if struck by lightning and writhed to the ground.  He arose, and shared that the river god had sent a reply to him.  It appears as if the river god no longer needed humans as brides or husbands, and would be content with the best of the grains.  From that time onward, the people of the river no longer feared for their children or feared the wrath of the river god.

Perhaps the nearby water or ravines that once ran to this lake echoed this tale of change in consciousness.  How often do we question the merit of our long held beliefs and practices?  How often do we change these beliefs and practices in the face of the sorrow of others?  Why does it take disasters or self-sacrifice for us to find motivation?  Time to go in, and get out of this cold.  The air is so cold that when breathed, it is as if one had eaten ice cream, and the head and brain freeze.  In ten minutes, the feeling may return to fingers, and they may be useful once again.  Now they are without blood for a while, and a dull pain is felt.  Excuse the author for a moment while he coaxes blood to reach the fingertips, to take away the pain and return their normal color.  It seems I have not spent much thought as to how to portray the mother of modern medicine, and this thread is important in the story of the last hundred years.

Mother of Medicine

Motherhood brings with it new responsibilities and changes.  The best of mothers are fiercely determined to see their children grown, independent, and successful.  They are tough when needed, tender when needed, sane most of time, and loyal to their family.  Ideals are instilled that map the future.  It is said that some pregnant mothers put up pictures in their rooms which make them think about what professions their children will choose.  Mothers will sacrifice for the education of their children so that they may grow up enlightened.

A child was born early in the twenty first century to such a mother.  Her single mother hung pictures of caring physicians in her room during pregnancy, and filled the child's room with these images when she was born.  The mother had little material wealth, and worked as a maid during the day.  She understood the importance of hard work, and respected any and all workers without judgement.  She insisted that family who sat the child during the day kept her focus on education.  At night the mother cleaned laundry for others but assured that time was spent teaching her daughter to read and write.  The daughter's education shaped where they lived, and how they spent any free time.  They walked along Museum row, and were frequent visitors of the science, natural history, medical history, and art museums.  They also visited the aquarium and planetarium, and took advantage of days with free admission. 

M. did very well in high school, and attended the University of Chicago on scholarship.  She went on to medical school at the same institution.  She was her mother's daughter, and realized the sacrifices required to get her on this course.  Her upbringing had prepared her to understand health care disparities based on wealth and race.  She had an inquiring mind, and a fierce devotion to her studies.  The professors were pleased that she sought them out for discussions after class, and appreciated her dedication and drive for greater understanding.  She wanted to know the subjects in depth, and understand the history of practices.  Policy directions were also important to her, and understanding change was critical.

Who was M.?  What did she look like and what did she act like?  What was she interested in?  Was she outgoing?  Since she is among us now most of this information is available from news sources as she has acquired some fame.  Briefly she is black, has dark inquiring eyes, and is thought to be attractive.  She is tall, and commands a group when she speaks.  She gives thanks to God for her gifts, and is a modest private person.  Her time is spent in giving to others, and she has sacrificed for her passionate pursuit of medical equality and improvement.  M. is married and the mother of a son.  Her husband is a banker in Chicago, and they now live a suburban life.  As you might expect, her mother lives with them.  

Because of her training in public health, she has pursued work at the health department and eventually rose to head the division for the city and then the state of Illinois.  She has been a leader in quality improvement and reducing racial disparities in medical care.  Her prominence in reducing food and water borne illnesses and population health programs is emphasized by appearances in the media.  When the Chinese sought out leaders, she rose to the top of their list.  Her relative youth and energy as well as her excellent training have set her apart from other candidates.  Her devotion to public health, process improvement, and equality of care, as well as an unblemished public image have made her an ideal leader. 

To be sure she has had detractors.  Some say she lacks experience, and does not truly understand the complexities of the system.  Some say she does not stand up to the corporate interests, and is naïve.  Others say she lacks the toughness required to live in a world of deception, treachery, and bold self-interest.  She charms her supporters and her detractors.  It is as if the only voices she hears are her mother’s and that of her family and community.

In choosing her "cabinet" or administrative staff, she has surrounded herself with accomplished bright people who present her with all sides of an issue before action is determined.  She filters the information, and then either requests more information or determines a direction.  Her work is reminiscent of the jazz music legend Louis Armstrong.  She smiles despite adversity, and makes her world better.  Her work is defined by concerted action.  Her individual performance is close to flawless, and the people around her are inspired by her confidence and success.  She leads a “band” that is energetic and works together combining individual strengths.


Wrong account


While listening to Coltrane the banker called to inform that the check written for the balance of the dwelling was refused for insufficient funds.  Since there are funds somewhere, let’s put the mother of medicine to rest for a brief period, and deal with personal life.  After a few calls and account discussions, the error is found as funds were transferred from an incorrect account.  The banker knows the modus operandi, and has given some slack.  The transfer was for half the value of the condominium, and must be re-sent.  The vision of a perfect world is once again shattered.  Why must one deal with these details when important work awaits?  I should have transferred correctly in the first place.  Of course I should have but all through life, the daily details often trip me while my vision is focused on the horizon.  Gracie looks at me as if she understands the frustration of an incorrect action, and trots along to the bank to right the wrong, and transfer funds appropriately.  This should all be done electronically but relationship is important, and I want to do this face to face, mano a mano (or is it hombre a hombre?).

Not so simple.  The orange train will take us downtown, and then another color gets us to the bank.  It is cold on the platform, and breath is steam from a small engine.  Everyone is huddled with rounded shoulders, and full winter gear.  Hats of every description abound but the people who amaze are hatless.  Do they not understand how much heat is lost from the head, or are they producing more heat, or do some enjoy being cold?  Another multiple choice with no correct answer.

The bank is around the next corner, and the warm lobby beckons.  The lady at the desk greets me, and am told to go in.  How does one feel besides cold?  I feel imperfect, flawed, and embarrassed.  Life has often seemed easier and less complicated than it is.  How many imaginary sail boats have crashed on the rocks in this life while the skipper was immersed in a discussion of the merits of a particular wine?  This captain senses the wind, the swift flow of the boat through the water, the island ahead with the flawless beach, and routinely misses the rocks ahead.  Optimists have this problem.  We set out on endless voyages with visions of clear sailing, only to have our hopes or plans dashed.  Some of us learn from our failures, and develop guarded optimism. 

A friend, the banker understands as long as one account has the available and necessary funds.  The funds are transferred, and we take ownership of our condominium.  Perhaps this was a good sail with minor setbacks, and successful avoidance of major catastrophes.  Now perhaps your author will shop the downtown, and let the project sit a little longer.  Medical mothers and histories are patient subjects.  They will be at the library on our return. 

Brick and mortar as well as glass and steel are evident in abundance.  This city has such vibrancy and energy.  Architects have competed to change the skyline in their unique style from the time of the fire and Louis Sullivan, but the lake and the river are critical to their efforts.  Add to this, great restaurants for every taste, world class mind-opening museums, and elegance, grace, and chaos are assured.  Since relationships are critical to understanding, trust, and passion, transactions still occur in these structures between people without electronic interfaces.  To be sure people use electronic devices for information and clarification, but the work is done with words, expressions, and trust.


Re work and wrong directions


Scent drew me up Michigan Avenue for caramel melted over popcorn, and we have wandered into the candy shop for this treat.  Window shopping completed, it is time to head south and back to work.  Perhaps the hologram should have alternative pathways for people to choose to see what has been, and what might have been.  This will also illustrate “blind allies” or short lived directions taken by the government.  This will help teachers examine choices, and be useful to test knowledge of the subject.  Museums will set up displays, and this will give them tools to engage the curious.  Decision analysis will also allow historical understanding of the interactions which led to the present system.  The interaction of politics and medicine comes to mind.

Despite the successful models in other countries and in governmental systems such as the Veteran’s administration (when properly funded and not ruled by corrupt officials), the politicians of the early twenty first century pursued a course solely based on reimbursement.  Up the platform, and on the south bound train, the thoughts continue.  The scenes of the city and the lake are the background.  In the foreground is the 2008 political election which focused on financing of medicine.  Quality of practice was either too difficult to work on or not a significant concern.  Even though the new proposals would cover nearly all citizens, they did little to change the procedural focus for payment.  Quality of practice and payment for quality were distant calls, small voices, academic pursuits, and had not yet become mainstream.  The mainstream efficiencies were all about discount from billed charges, and not about encouraging thoughtful careful practice, appropriate care, resource allocation, and coordination among system members.

To be sure reimbursement models such as those in Massachusetts and other states were simple and understandable.  The fact that they were unworkable and unsustainable had not yet become common knowledge.  The fact that quality and other critical variables had to be accounted for was yet to be generally understood.  This was remarkable considering that poor quality had undone the American automobile and steel industries over the decades before and after 2008.  American blindness and optimism were politically acceptable.  Truth to power had little effect.  Power was both deaf, dumb, and blind.  Industrial leaders looked for simple solutions and despite advice from consultants and academics, looked for patches.  Long term solutions were ignored in order to achieve quarterly financial goals needed for executive compensation goals. 

One of the candidates was rebuffed for earlier attempts to bring together consensus builders.  What is good in music, what is pleasant to large numbers of people, what is easy to listen to is not always the answer or the opening of a serious discussion.  The public seemed to be disinterested in complex discussion which involved discord or discussion of imperfections in a system that they trusted to be perfect.  They were not interested in hearing objective discussion about surgeons or doctors who they had already accepted or needed to be “good”.  For this reason and many more, new programs arose that extended the programs available to federal workers to the general population. 

Once these programs were in place, and most were covered, the bills started coming in.  Under the auspices of the Affordable Care Act, the system slowly ground to a halt like an expressway in Los Angeles because industry, government, and the people were unable to pay the bills.  More recipients of care meant already stretched resources, and many providers would focus on those who maximized their reimbursement.  The Democratic backed plan was a constant sign of failure to Republicans who fought every change in the system.  Partisan politics and polarizing issues brought the nation’s ability to govern to a standstill.  Default became common, and bonds issued were of lower and lower quality.  Investors began looking for other alternatives, and the system continued to slowly deteriorate.  History proceeds and allows those of us who study it to marvel at events as they unfold.  It is frequently not what we would have wished would have happened.  In retrospect we wonder at wrong directions and missed opportunities.


Hunger distracts again


Mens sana in corpore sano.  Dog and man are back from a vigorous walk, we return to the library, and prepare for sustenance.  While the mother of medicine awaits, the stomach growls.  Sublime? Ridiculous?  Neither?  I have packed some goodies for Gracie and me.  Freeze dried soup, lentil with ham which will be ready once hot water is added, will do for this human.  Gracie has a bag of kibble and some treats which, along with some fresh water should satisfy her till dinner.  The lentils and ham are wafting up in the warm mist from the bowl, and now a texture and complex set of colors have replaced what was once gray green powder.  Some crackers from the nearby machines would be nice with the soup.  I wave a card in front of the reader, and soon the account is debited, and my soup has crackers.  Warm food and pleasant aromas counter the cold outside, and give strength to this endeavor.  The warmth also hints at the end of cold weather, and the return to moderate temperatures.  Hope is eternal, and often based on the return of spring.  Adding to the hope is a packet of Girl Scout cookies.  The new varieties available from nieces in the business are another indicator of spring’s proximity; some good things do not change.  The occasional brutal cold and mind numbing wind require that Chicagoans turn their thoughts at this time of year to seed catalogues, confections, and a variety of stews and soups.  The theatre, symphony, opera, and other arts help warm the winter days as well.

Our medical mother, the valiant crusader mentioned above is not perfect.  She and her organization have their share of concerns.  As in all complex governmental systems, graft and corruption, fraud and abuse account for many wasted assets.  Committees are busily hunting out new schemes and perpetrators.  As Harry Truman found years ago, the scourge of corruption feeds at the margins of all great endeavors and all governmental troughs.  The need for fly swatters, mouse traps, and poison bait will always be with us to deal with opportunistic incursions.  As long as there are surpluses or concentration of spending devoted to one governmental societal concern, there will be those with legitimate and illegitimate demands made on the favored cause.  The temptations to those tasked with purchasing services for the government are overwhelming.  The author’s father, a retired judge with a reputation for honesty and fairness, once joked that he had never been offered something he could not refuse; temptation had never been so great that it would lead to a life reversal.

Usual concerns such as feeding, clothing, educating, and sheltering are the underlying pressures.  Add to these the demands of the ego as tested by quest of physical beauty, gambling, drug taking, and sexual needs or desires.  It is amazing that the weakest link in most systems, the human link, does not break more often.  It is one thing to live a life free of sin with few challenges.  It is quite another to resist temptation when it is regularly presented.  In the case of our mother, not a week goes by without offers aimed at buying favors, buying business, or buying contracts.  She is heroic in her focus, and resistance to so many veiled offers.  Microchip monitoring has substantiated her resistance to proposition after proposition.  The cynic would deny the heroism of such an individual.  The degree of monitoring we live with is unprecedented.  No event goes un-noticed or unknown.  All actions are heard and seen, and records are kept.  We need remarkable people, and it is fortunate for us that many exist in any age.  The bureaucracy tasked with financing and monitoring health care is under tremendous pressure even though we no longer spend one of four dollars earned for health care.  Early in the administration of this system the percentage of gross domestic product has dropped from a record of 25% gradually to a current 10%.  This change occurred over twenty years.  Still one out of every ten dollars earned is a great sum.  To be sure more people enjoy coverage, and the amount of resources consumed by the health care process add up to an impressive sum.  Like any collection of wealth that must be budgeted, and gradually paid out over a period of time, prudence is necessary in administering the disbursement of this trove of tax dollars.


The Campaign for President of the U.S.A. 2008


This train of thought leads to the election campaign of 2008.  The Presidency of the United States is always a great prize for the winner.  The candidates back in 08' were a diverse group.  Health care had come to the fore as an issue which each candidate felt the need to expound on.  The amount spent on health care had nearly ruined the ability of American companies to compete at home and abroad.  A woman candidate led the discussion, and proposed much of what we accept today as standard of care.  Her suggestions were to listen to the people and give informed choices, implement Universal coverage and offer plans such as Congressional  members had to choose from, and implement electronic medical records in order to better track and improve care.  Her proposals to fund the system were less clear, and her plans to transition from the system of care at the time were poorly developed.  Though she was vague on detail, her vision was sound.  It was unclear what people heard of her message.  Did they see her mouth move, and not hear or trust her words?  Did they see her mouth move, and assume she was lying for her own aggrandizement?  Did they see her mouth move, and turn off the viewer?  Did they see her mouth move, and get excited about the possibilities?  Did they see her mouth move, and think of how such ideas might be implemented?  Her mouth continued to move whatever the result.  The archives are a rich source of her exposition.

Her issue was probably premature in capturing the public outrage.  At the time more pressing issues seemed to include homosexual marriage rights, abortion rights, immigration policy, stem cell research, and the continual war in the Middle East.  Her issue was critical to the populace but easy to cover over with other topics.  How many people would go with no care or inadequate care before this became a political issue of consequence?  In fact, the number of un-insured or those with no health care assurance rose to one third of the population by 2016, and the outcry became real and painful.  Most were less concerned about the un-insured, and yet concerned about American industrial competitiveness.

In the election of 2024 candidates talked, their mouths moved, and people listened.  They heard of mother's dying of curable thyroid and diabetic problems, they heard of children dying of curable infections, and they heard of countless people turned away from curative care for the lack of means to pay.  They heard the cry of American industrial competitiveness.  The issue had finally risen to national concern.  The time had arrived for this issue to be heard as a priority issue.  The American dream was not simply home ownership, car ownership, and a piece of the economic pie.  It came to include health care assurance without which the other possessions were of less importance.  Echoes of the 2008 campaign, and other campaigns back more than fifty years were finally heard.  The candidates of yesteryear were removed from the historical closet, dusted off, and sent out as spokespeople to campaign for change. 

Though they were back on message, the progression of lasses faire medicine had been inexorable.  "Non-profit" organizations had squeezed most of the nation's resources into their tills.  The rich had feasted as the poor died younger and younger.  Poor planning and competition among non-profits had left a system with a different and confused vision.  The ambient vision was maximum profit, maximum resource utilization, and maximum growth.  Competition was brutal with an eye towards bankrupting competitors, and sending them out of the "industry".  These kinds of tactics and results were mirrored in the music of the time, and apocalyptic visions were rampant.  With such abuse of power was it possible to save this world?  Had we gone beyond Sodom and Gomorra?  Had we surpassed Rome in our avarice, our narcissism, and inability to see beyond our own perceived needs?

Echoes were heard back a century.  People of vision and beneficence had been calling our attention to this problem for years.  Their mouths had moved but it took a long time until a majority would hear and understand.  An Affordable Care Act had only increased the behemoth resource demands of a broken health care system.  Even then it was too late for in-system change.  Too many obstacles stood in the way.  Too many “haves” blocked the paths of the “have-nots”.  The people who held power were entrenched, and inertia was too great.  But even as a great weed seems to dominate certain landscapes, it has a source of sustenance.  Because of its demands, it is dependent.  Financing for growth and resource use was the source of sustenance.  The stream of money was followed, and the source of the funds saw the end of profits and the beginning of increasing debt.  As would any prudent farmer, the financiers looked for better prospects.

Millennium Park


One does not live by history alone.  Time to get out and smell the fresh breezes off the Lake.  Our walk and bus connection has taken us to the center of the city.  The public art near the Art Institute is our focus.  Both Gracie and I marvel at the reaction people still have to a sculpture fondly referred to as the Cloud Gate or the "Bean”".  Unlike many pieces of the early century (21), the “Bean” was made to be touched, walked around, and marveled at.  People seem drawn to it just as they were when it was first unveiled.  They stand afar to watch their own images and those of others, they walk up to its gleaming mirror like surface, and then under its concave belly.  Some drive by at a distance and never come closer.  Even these cautious observers are drawn to the “Bean”, and the people it has attracted.  Gracie and I look as distorted as are minds sometimes feel, as we approach the surface.  The dog is not confused by her image, and gives much less attention to it than the humans do.  Perhaps I am confused as to the state of her mind.

On a bench nearby we pass time on this unusually temperate day.  The “Bean” suggests that we might live in harmony with complexity, and enjoy even the most difficult to understand forms.  News from the year 2007 comes to mind.  After performing millions of procedures known as coronary angioplasty or balloon dilatation of narrowed coronary vessels at astronomical cost, the procedure was found to be no better than medical therapy in most cases.  The total of wasted 2000 dollars due to construction of facilities, development of machinery, professional training, and professional costs would nearly fill Lake Michigan.  How much suffering and pain occurred before this result was known, and how many years passed before the message got to the practitioner community?  How would a procedure like this get so much momentum before showing improved outcomes?  These were the kind of errors that contributed to the change.  People are comfortable with complexity as long as they benefit.  When they lose their health, have their bodies abused and manipulated without improvement, and suffer financially, at some point they start listening for suggestions for change. 

EMC, Excellence in Medical Care had a message for these people.  With EMC patient process and agenda focus made sense to some.  It would take more such health system abuse and more people without coverage for the concept of outcomes-based care to become part of medical training.  The goal was attainable best outcomes.  Like the “Bean”, they proposed a system that was simple in appearance but extremely complex and detailed in design and construction.  They no longer advocated incremental change.  They pushed for a new construct, or revolution in health care.

These musings have led us to confront the lions who guard the Art Institute.  What grand animals!  What proud expressions!  Gracie naturally barks threateningly at the bronze creatures, and we hurry past the crowds to alleviate her anxiety.  It is time to return to the archives.  We cross the street, and enjoy the store windows as we head south.  I would like a coffee, and we turn into a shop.  Long ago our little canine friend would be unwelcome on such a trip, but with age our city has come to recognize the importance of pets and they now are welcome at coffee shops.  This shop has a plate of small dog bones for the four legged friends.  Gracie takes hers in one ravenous bite, and a few chews before a swallow.  Warmed and comforted we proceed back to the library.

On the train, thoughts are drawn to an important dialogue of last century.  On one pole were the majority of voters for most of the century, and on the other were those who claimed health care as a right.  The great American democratic experiment clearly claimed life, liberty, and the pursuit of happiness as rights but in dispute were feeding, clothing, sheltering, and providing health and medical care.

Do Angels watch us and listen to us?  Rights and rites

Those who eloquently argued in favor of health care as a right usually asserted so as tautology.  They argued that in a beneficent society those with the means should provide all citizens with health assurance.  In this construct proper nutrition, clothing, and sheltering are assumed.  Further in order to have a democratic social contract with the governed, all must share in the success and largess.  The argument based its conclusion on the historic tribal life, and the contract present in many developed countries of the time.  In these scenarios, health care was provided to all members independent of their rank or wealth.  The argument was the appeal to humanism.  How would we avail some members of the community curative care, while turning others away?  Was it right to refuse Bessie Smith care, and offer the same care to another based on race, gender, or other differentiating factors?  Was it right to experiment on one group based on race or gender as in Tuskegee, for the betterment of others?  The wise suggestion or veiled threat in this argument was that if others wanted to continue to enjoy health care, they must provide care to their disadvantaged brethren.  The racial disparities in care were raised.  At that time the life span, blood pressure values, cancer care, and diabetes statistics were markedly different for people of different races and cultures.  American Indians, Hispanics, and African-Americans had higher death rates, blood pressure values, and blood sugar values compared to Caucasians.  As in any negotiation, the mantra was go for the moon, and accept an earthlier sum.  Most people who advocated for this right were realistic in assuming that they would accept entry into the system.  They realized that in all systems there were many tiers, and that entry would be an improvement to what was currently available.  Basic concerns were vaccinations and other preventive care, emergency care, community health programs aimed at safe water and waste disposal, protection from bioterrorism, affordable medications, catastrophic care, primary care with family orientation, reduction in gun and vehicle violence, and health education.  Quality in care was generally not considered in these discussions.  If others got what they needed or what they did not need, those who pushed for the right to care wanted it all.  Lifestyle modification was also not a part of the discussion.  Smoking, overeating, drinking, and abusing other toxic substances were rights.  The focus was on getting what was perceived to be what others had.  Outrage, religious zeal, and the use of personal vignettes were used to put the message squarely in the face of the electorate.  Appeals were made for decency and fairness.  The line was drawn between the "haves and have nots".  The majority of voters were concerned about the ever increasing gaps in wealth and privilege.  The wealthy wanted to keep their industrial products competitive, and sought health care reforms as a means to reduce costs.


Those opposed to providing care were primarily opposed to paying for others.  Here also the arguments of quality improvement and lifestyle modification were ignored.  It was assumed by proponents that the health care they received was the best in the world.  They pointed to anecdote after anecdote to prove their point.  The richest people in the world still came to America for their care.  There were more high technology diagnostic devices in most American cities than there were in many other countries.  People from other countries such as Canada came to the U.S. for care to avoid waiting in line in their own land.  American access to new techniques and new medications was second to none.  They had what they needed, and they had worked for these benefits.  Why should they have less, pay a greater tax burden, reduce the profit of goods and services provided so that other might have access to something they had worked so hard for?  The community statistics they were interested in were their own.  If the U.S. infant death rate was high, it was not their concern because their children lived; children of others were the concern of their own parents.  The cost of providing care for all would lower the lifestyle of those opposed, and lower the competitiveness of their goods and services in the world market.  How would you trust a government to provide health care which had failed so miserably to protect the health care of seniors, service members, and veterans?  The majority was proud of their care, their doctors, their hospitals, and their health.  Let others work hard to achieve this level of care. 


In retrospect this discussion brings to mind the right of freedom.  Those who had battled "Northern aggression" in the previous century were unwilling to further share their holdings with those who lacked.  Clippings from this period point to many who had different views.  Confusing the discussion were the problems with immigration.  Because of the complexities of the American business community, immigrants were needed to do some jobs such as picking grapes or harvesting other crops.  As a result, the border with Mexico was not well guarded.  Large business interests wanted lax immigration, and of course did not want to add to their costs by assuming the bill for health care.

The other confusing part of this discussion or debate was health care as a transaction.  The myths and historical dialogue focused on health care, where the primary cost was the time of the healer.  Little expensive equipment was involved.  To be sure time must have been spent gathering knowledge, herbs, powders, and other accoutrements of the art.  As the twenty first century dawned, the health care transaction was a much more resource intensive practice in allopathic medicine.  Medicine had become big business.  The choice of artificial joints, the choice of medicines, the choice of facilities, and many more choices had more to do with marketing than with the quality of the service.  Many practitioners swore they were not part of, and even hated the business.  However, it was inescapable that a transaction of any kind with the system was expensive, and no longer would barter be an acceptable exchange for care received.


The train station is ahead, and it is time to end this reverie.  I will get the clippings and video footage to insert a section into the hologram on this debate.  It did not gain the necessary public interest until the 2024 political season.  That year it became a deciding issue, and many elections hinged on how a candidate stood on health care.  Some of the speakers were eloquent, and their outrage impressive.  Some were able to engage the viewers with reasoned positions.  Mostly the voters had already decided change was overdue, and determined their vote by opposition to the system of the time.  It was time for a change.

Incremental change of large social systems such as health care delivery is generally better tolerated than transformational or revolutionary change.  This position is better tolerated by most people.  Some previous feudal systems remained in place for centuries because of inertia and ignorance.  Neither of these abetting factors were part of the 2024 campaign.  The people had been educated over twenty years prior, and the legion of uninsured were ready to knock down the barriers of inertia.

Even Tolstoy alternates the sublime with the ridiculous in deference to the reader’s ability to sift the historical data.  Even such an immodest comparison deserves consideration as we discuss these weighty matters.  We have forgotten to get off the train on occasion when engaged in such reveries, and we soon recognize our nearing station.  We will not pass the stop this time as Gracie is anxious to meet another canine she has seen on the platform outside of our window.  By her posture, with her rear legs set, and her eyes fixed steadily on her nemesis, I will need to shorten her leash and hold her apart.  She is a wonderful companion but always alerts me to the presence of another dog.  She regularly receives a failing mark in the section “plays well with others”.


Generational outreach


As I walk back to the library, I am reminded of the words great grandmother spoke in anger or desperation about limited knowledge and ability to help in her care.  Another voice is heard as well.  A very good friend of father’s used to engage me beyond pleasantries of conversation.  He would face me, fix my eyes on his wizened head characterized by bushy black eyebrows and black hair with shades of gray, and ask what I wanted to do when I grew up.  He continued to ask me this question beyond medical school, beyond training as a doctor and researcher, beyond years of teaching and research, beyond caring for patients, and until his death.  Did he have an answer in mind?  Was he testing whether my ambition compared to his?  He had risen from bartender in his father-in-law’s tavern to Chief Supreme Court Justice of the State of Illinois over his career.  Was he simply trying to engage youth?  Did he sense that I was restless and would re-invent myself every five to ten years?  Was it beyond comprehension that a doctor was not in practice in the community of one’s birth?  Would this work have been more comprehensible if he were to see the author golfing at the country club, or sharing bourbon and stories at the bar?  To this day I believe he was happy for the achievements, but wanted to give greater expectations to strive for.

These are fond memories of this dynamic man who pressed me for an answer to a critical question.  He was a friend and mentor who helped gain insight into actions and existence.  Often the thorny confrontational friends are greatest help in learning to better face life.  I have a passion to improve medical care, and have expressed that passion in a number of ways.  This historical work is an attempt to help others better understand our past in order to improve the future of health care.  Fundamentally a teacher depends on students for mutual growth.  Some view a life as inconsequential if not lived in a particular role.  Others will spend more time in understanding the irregular path.  Generations often fail to understand the other when they stereotype, and avoid learning or listening.  To this day your author is simply trying to do one good thing before life ends.

The blank stares that have greeted me for years when asked to explain this work are evidence of the fact that more information has been given than people are ready to accept.  To stop at a label such as doctor, lawyer, teacher, fireman, or policeman would be acceptable.  To go beyond into one’s passion becomes monologue.  People want to hear about success and failure, recognition or infamy, and promotion or demotion.  An introvertcarefully avoids these battlefields in life.  Personal energy level increases with solitude, and diminishes with acclamation and social interaction.  I love being around people at times but need the quiet walks with Gracie, and the contemplative time at the library.

Most people are extroverts and thrive on regular contact and interaction with others.  These people gain strength and energy when with others.  Do they understand the few introverts in their midst?  Do they see us as standoffish or cool?  Do they think us proud and vain?  Are they willing to walk in our shoes?  Are we willing to walk in theirs?

Maimonides wrote centuries ago that one should only earn enough to live on.  We should seek to provide food, clothing, and shelter.  The main effort of life should be devoted to family and devotion to God.  Perhaps this would have been the best reply to the bushy-eyed extraverted friend and mentor.  His question will remain an enigma all the days, but I hope this life gave him some satisfaction that the next generation would carry on.  What is clear is his wish for life to be consequential, and I will try on his behalf as well as the behalf of parents and grandparents and so many people; to live fully and stay engaged while surrounded by family, work, and devotion.  A life led with no or low expectations or ambitions, with avoidance of confrontation at all costs is incomprehensible.  To beat a person down beyond expectation is a tragedy and incomprehensible.  People seem to rise or fall to expectations.  If you believe there is no greater resource than humanity, then expectations are a necessary part of our growth.


The concordance of factors


EMC, the mother of medicine, and the Chinese vendors were the necessary forces that led to the bloodless revolution in care.  Their expectations were very high.  Was everyone happy?  Did most people understand what had happened?  It is beyond the scope of this work to explore those questions.  In fact, I will work with colleagues to explore these questions in the future.  Many Ph.D. thesis topics will take facets of this question for analysis and better understanding.

Essentially the Chinese creditors became like a vendor that the US “hired” to manage the health care system.  With this arrangement there was no longer competition in health care.  The vendor determined the site of facilities, the type of diagnostic equipment, and the content of the basic health plan.  Universal coverage had been enacted earlier in the century.  The Affordable health care act of 2014 set forth the basic care package but until the “vendor” was in place the market remained chaotic.  With their intervention is 2026, significant and orderly change occurred. 

The large “non-profit” health care organizations balked at these changes.  They had become accustomed to building facilities proximate to other “non-profits” to compete for business.  They used their fantastic financial tax-free windfalls to build greater complexes, travel and build luxuriously, and generally bully their communities for their own purposes.  Most had grown to shun charity care, and in fact gave much less such care than for-profit hospitals who also paid taxes.  These organizations now fell under a regional planning authority which coordinated the facility construction, and became part of a larger health care plan. 

Electronic medical records, interconnectivity of records, and electronic evidence based algorithms were instituted in all facilities, and physicians were brought into group facilities.  Exceptions were allowed but these mainly catered to the rich, and those doctors and caregivers who did not meet governmental standards as set out in the act of 2024.  They became a fringe element, and were no longer a tax drain.

Information gained from the electronic record was used to improve quality of practice, improve efficiency of practice, and improve continuing education of care givers.  The use of this massive data base led to improved emergency care, improved medical research, and improved care in general. 

By eliminating a competitive health care market, the profit was no longer present in replacement body parts such as artificial hips, in providing medications to be taken by mouth or by injection, and by use of expensive diagnostic equipment.  Taken as a whole the “vendor” did very well providing for the care of some 350 million people, but the percent of the gross domestic product devoted to health care dropped from 25% to 10% over three decades.  This in turn improved the ability of the US manufacturers to sell their goods in the world market, and improved the balance of trade.  The US got back on its feet, and became a world competitor.  It became a better place to invest, and set the stage for the recovery we now enjoy.

Non-profit facilities became once again a source of community pride.  They were no longer business machines used to process patients.  Though there were far fewer than there had been at the turn of the century, the few that survived were community anchors.  Jobs at these facilities were important to the community but no longer were the major employers in most cities.  Manufacturers and processors once again became the major employers now that they were no longer overwhelmed by the costs of health care.


Union Station


It is time to put this work aside, and pack up.  The wife is coming back from Texas this afternoon.  With the advent of fast or bullet trains, the San Antonio to Chicago run of the Texas Eagle takes four hours.  Hardly time to settle in, get a drink in the club car, and read correspondence or good fiction.  Both Gracie and I have missed M.  We are all lonesome in our unique ways when apart.  These separations are necessary to accomplish what we do.  With them we have greater family reach, are able to attend more events, and also feel able to achieve professional goals.  We each are strong individually, but synergistic as a couple.  She tells me that the visit with her grown children and grandchildren went well.  They had meals together, planted new shrubs, and conversed late into the night (which for us is rarely beyond 10 pm).

Before leaving I browse the catalogue for entertainment for our reunion.  We enjoy watching, and eventually falling asleep to old classic motion pictures.  Our favorite categories are musicals, documentaries, dramas, and comedies.  The heaven theme intrigues me lately, and titles such as Children of Heaven, Warriors of Heaven and Earth, Heaven over Berlin, and Days of Heaven come to view.  I go with Children of Heaven to temper world view, and renew a sense of innocence.  The picture follows a young Iranian boy and his sister through the trials of sharing a pair of shoes.  Sounds pitiful and sad perhaps but the acting and story twists make it a lovely heartwarming tale.  The picture will run on our home viewer after a wine and cheese reception.   We live in a golden era for such entertainments.  The transition from two to three dimensional images was significant, but the old flat images have their charm.  One hundred and fifty years have passed, and great performances have been recorded.  It is all one can do to see the best of the best.  These performances never fade.  For example, the Mother Superior’s advice on following dreams and rainbows from the old classic Sound of Music, and Maria’s many admonitions to the children on staying positive whatever the situation go straight to the heart of many a sensitive person.  “Whistle a happy tune”


The library is quiet as most students, researchers, and other users have gone home.  I leave our work out on the table top, and tidy up.  On the way out I greet the librarians, and thank them for their assistance.  They are friendly and helpful, and have been important in the work.  The bulletin board is full of advertisements, help wanted requests, and notices of classes or concerts.  The staff has posted the initial showing of our hologram for one month from now.  It should be complete, and references checked by then.  With the winter coat fastened, gloves on, hat and ear coverings in place, we are ready to face the wind and the cold air.  Out we go into the chilly night.  The weather has moderated and the wind has died down.  The sky is dark, and the stars shine beautifully in the clear night.  The familiar walk to the train begins.





2008, 84, 87

2008 political election, 83

a coronary special care, 12

a cottage industry, 16

acne rosacea, 10

acute care, 34

addicted to drugs or alcohol, 18

advertisements for medications, 43

affability, ability, and availability, 22

Affordable Care Act, 84

Akira Kurasawa, 56

alien hyper-leap, 4

Angels, 92

Annals of Internal Medicine, 6

anti-coagulant, 12

Art Institute, 90

Asses or elbows, 47

Assessment, 10

attainable best outcomes, 91

attending internist, 11

balaclava, 71

Bean, 90

beneficence, 38

beneficent society, 92

Bessie Smith, 93

billboard reputations, 25

blanket of outrage and suffering, 24

blood transfusions, 12

boomer generation, 27

breakwater, 76

bubbling cauldron, 24

business, 17

Cadillac, 49

cake, 9

Canadian or British health care systems., 73

cancer care, 35

cardiac catheterization and angioplasty, 11

care for himself, 28

care should be directed toward sustaining or returning one to health, rather than fighting the inexorable ravages of disease if possible, 31

Care should be ethical, 30

care should be of value, 31

caregivers, 13, 17, 19, 28, 100

Casablanca (1942), 59

catheterization laboratory, 12

Center of excellence and value, 73

Cervantes’ stories, 51

Chicagoans, 86

Chief concern, 7

childhood mortality, 6

Children of Heaven, 102

China, 71

Chinese creditors, 99

classic motion pictures, 102

Clinical course summary, 11

Cloud Gate, 90

coding and reimbursement sub group, 74

Coke bottle glasses, 49

Coltrane, 81

community anchors, 101

community pride, 101

companions of the canine variety, 42

competitive health care market, 101

concordance of factors, 99

Consumer bodies, 74

continuing education of care givers, 100

Cook, 23, 49

Cook County Hospital Association, 23

cottage industry, 16

coverage decisions, 74

Cuban cigar, 48

curative care, 89

D., 33

Deerfield, 16

delivery process, 15

Democratic, 84

Dickens, 14

dignity, 33

do no harm, 21, 31, 36

documentary hologram, 5

Don Quixote, 50, 51

Dr Middleman, 16

Dr. C., 22, 40

Dr. Middleman, 13, 20

Dr. W., 30, 32, 41

Dr. X., 29

drinking, 17

editorial, 36

electronic interchange standards, 40

Electronic medical records, 100

electronic records, 19

EMC, 24, 36, 37, 46, 74, 91, 99

emergency care facility, 7

evidence based algorithms, 100

excellence in care, 74

Excellence in Medical Care, 24, 73, 91

extroverts, 98

fashion police, 71

financial incentive to do the wrong thing, 36

finest doctor, 20

finest hospital, 20

Five percent, 59

foreign influence, 72

for-profit hospitals, 100

Frank Lloyd Wright, 75

fraud and abuse, 86

Generational, 97

gold bullion, 72

good guy, 19

graft and corruption, 86

Grand Canyon, 5

Great Grandmother, 4

group practices, 16

Guernica (Pablo Picasso), 53

guidelines, 15, 19

harm, 14

Harry Truman, 86

health care assurance, 89

health care disparities, 79

health care regions, 74

health care system, 24

health plans, 16

heaven theme, 102

high health care costs, 73

History of present illness, 7

Holocaust, 5

hospice movement, 48

Howard's End, 57

Hunger, 85

Hyde Park, 76

Indian tribe, 76

infusion of brilliance, 4

insurance plans, 16

interconnectivity, 100

Inter-dependence, 15

introvert, 98

just say no, 37

king of the mountain, 41

Koch’s postulates, 49

lasses faire medicine, 89

lawsuit, 13

left main coronary artery disease, 11

legislative gridlock, 19

Letters to the editor, 20

Lincoln Continental, 48

Louis Armstrong, 80

Louis Sullivan, 82

Maimonides, 99

maintenance of health, 34

major networks, 44

Man facing southeast or Hombre mirando al sudeste (1986), 51

Marital, 17

massive data base, 100

McCarthy (All the Pretty Horses), 57

measures of quality, 40

Medical Industrial complex, 32

Medical Society, 21, 22

medical students, 15

mergers, 8

Millennium Park, 90

molten lava, 63

Mona Lisa, 62

monitoring health care, 87

Mother of Medicine, 78

Mr. A, 6

Mr. A., 7, 8, 13, 16, 20, 30, 34

Mr. B., 63, 64, 65, 67, 69

Mr. B. 2048, 63

Mr. L., 28

Mr. R., 23

Mrs. A., 21, 24, 34, 37, 73

Murakami, 70

Murikami,, 52

Museum of Science and Industry, 75

Nano chip, 33

napping, 51

networks of doctors, 16

new health care system, 72

New medications, 38

non-profit hospital, 18

non-profit” health care organizations, 100

Northern aggression, 95

nurse care coordinator, 69

objective system, 20

operation, 30

opportunistic incursions, 86

outcomes-based care, 91

passionate pursuit of medical equality, 79

Past Medical History, 7

Pasteur’s influence, 49

Performance, 18

performance measurement, 16

perpetrators, 86

pharmaceutical, 17

pharyngeal leukoplakia, 10

Physical examination, 9

Plan, 11

poor care, 26

practice guidelines, 40

prevention of disease, 34

procedure code, 18

public health, 79

pulmonary embolus, 13

quality of care, 27

quarterly financial goals, 84

racial disparities, 6, 79

raids on US assets, 73

rainmaker”, 17

Rashomon, 62

Rashomon (1950), 56

Ravel’s Bolero, 73

referral center, 11, 12

regional planning authority, 100

re-organizations, 8

replacement body parts, 101

Republicans, 85

Review, 9

revolution in health care, 73

right thing at the right place and the right time, 36

river god, 77

rock the boat, 19

Rome, 89

Saramago (Seeing), 57

score cards, 74

seed catalogues, 86

Senryu, 70

Shakahachi, 70

should be based on studies which have shown the best outcome with a particular approach, 30

small font disclaimer, 43

snake oil, 43

Social History, 8

Society, 21, 22

Sodom and Gomorra, 89

Sound of Music, 103

staff cardiologist, 11

stent, 12

synergies”, 8

take-over, 73

Tangled, 52

tautology, 92

tax-free windfalls, 100

technology leapfrogs, 40

that people chosen to pursue health care careers must first love other humans, 31

The Simpsons, 45

their circled wagons, 21

Tishiro Mafune, 58

Tolstoy, 50

torture, 28, 29

Transformational change, 25

transformations in medical care, 53

Truth, 33

Tsotsi (2006), 59

Tuskegee, 93

two sets of books, 18

University of Chicago, 16, 79

Whistle a happy tune, 103

white light, 28

Wim Wender’s angels in Wings of Desire or Der Himmel uber Berlin, 1987, 72

yuan, 71

Yuan, 71