Archive for the ‘GENERAL STUFF’ Category

COULD WE FINALLY GET A DOCTOR TO SEE THIS PATIENT?

September 8, 2019

A physician-friend of mine consulted me the other day about an unusual symptom.  I don’t get consulted much these days—I’m old, out of date, and nowadays just about everybody seems to be a medical expert either through being or knowing a first responder, nurse, PA, or some of the people I know in the hiking club.

Anyway, my friend had flexed his neck and felt a shock go down his body for a few seconds. He wondered if he were crazy.  Few things are as clear to a neurologist as this Lhermitte’s sign, named for the Frenchman who first wrote about it.  This means there is a problem in the cervical spinal cord, either due to MS, if the person is young; or arthritic changes or cervical spondylosis if older, with a spinal cord tumor,  foramen magnum meningioma, or Arnold-Chiari malformation, where part of the cerebellum, called the tonsils, tries to join the cervical spinal cord rather than staying in the skull. I did a brief exam, which showed no weakness, and told him he needed an MRI of his neck. 

He saw a nurse practitioner and convinced her that he needed an MRI.  That was done, and the radiologist wrote a report and sent it to the office.  The nurse in the office, not the NP, and certainly not a physician, read the report to my friend over the phone, which showed “moderate changes at C3-4,” mild changes elsewhere.  Nothing else. No future care was offered.  

In my practice, I not only saw the report but felt I should look at the films, often with a radiologist, and then call the patient and discuss what was next. The radiologists loved it when a clinician showed up by the alternator where the films were stored, and I learned a lot, too. I called my patients with the results and returned their calls. I wasn’t paid to do this and I never expected to be.  It was part of the office visit, in my opinion. It was not a fun part of the job, but it was part of the job.  I can’t remember any time in the past six years a treating physician—or a midlevel, for that matter—called me.  Even with email queries, only once has a physician has ever responded to me.  Something has been lost.

I told my friend he had to get a diagnosis.  Lhermitte’s is not some minor ache and pain associated with growing old.  It isn’t mild deafness or an early cataract.  This is a potential problem when mid-levels take over a lot of care and physicians don’t closely oversee it. Midlevels are excellent physician extenders but should not be considered complete physician replacers, either. I told the physician to get the CD of the images and I would look at it with him.

When I looked at the images, spinal cord compression at C3-4 jumped right out at me.  There was a 2 mm offset in a person with a small spinal canal to begin with, meaning that there wasn’t ever a lot of room for the spinal cord, and the slight change in alignment had removed 2 additional mm.  This was severe.  It explained the Lhermitte’s sign, and the question was how it should be dealt with.  He then called his primary physician, who made a referral to the spine clinic.  

My friend got an appointment six weeks out—-with a PA.  

This is discouraging.  This problem is a major cervical cord issue that explains a classic symptom that needs to be addressed sooner rather than later, and it shouldn’t have to be screened again six weeks later by another mid-level.  It’s frankly insulting. It’s time for a doctor to see this patient.  The referring physician dropped the ball, too.  At least it’s real pathology. This isn’t a person with a little osteoarthritis.  When I saw “headache, emergency, rule out bleed,” the headaches were almost always tension.

My friend has to wait, and it is a grim reminder that Oregon is not physician friendly and has a hard time attracting and keeping doctors.  I still haven’t a new internist a year after my other one left, although I’ve seen a physician assistant twice.  

The more recent appointment was for my injured hand which I got losing an argument with a rock on a river crossing on a backpack of the Timberline Trail around Mt. Hood.  I had a second metacarpal fracture, closed and non-displaced, and the diagnosis made, after which I elected to go to the local orthopedic institute to make sure my hand was going to be properly treated.  It is, after all, a broken hand. I did a lot of reading about broken hands, just like I do with other conditions I have.  

I went to the orthopedic center and saw…a NP.  She put me into a splint, which made sense, but again, I have to wonder, why aren’t doctors seeing routine real pathology?

Don’t get me wrong. For years, I spoke to first responders in Benson, Arizona, about head injury.  I had a video made at one hospital showing my dissection of a human brain, one of many I did, a crowd of nurses around me, so they and others could see the structures.  I did this, because I like to teach and I wanted ancillary personnel  who saw patients to increase their knowledge.

I now feel I need to direct my care a lot more than I thought I ever would. I’m on my own, the way I was on Mt. Hood, deciding to keep hiking another 30 miles with an injured hand rather than bail out at Top Spur Trailhead.

I worry, however, how I will deal with something serious in the future, and given the opiate issue, I worry greatly should my wife or I develop a painful condition— like metastatic cancer.  There are too many barriers between us—both retired physicians—and a treating physician. They are physical as well: I go into a medical office these days, and I need a GPS to find my way back out.  It didn’t used to be that way. 

I find it odd that when I was in medicine, I treated all sort of things that my training never touched upon and didn’t treat many things—carotid artery disease, and MS, to name two—that I had the training for. Internists would treat those conditions and send me people with obvious tension headaches.  Now that I am away from medicine, I am subject to non-physicians as gatekeepers and wonder what will happen if I am not mentally sharp enough to check what is happening. I am starting to be far more assertive about what I think needs to happen.

I also wonder what my friend would have done, if he were not medically trained and hadn’t contacted me. He would have eventually become diagnosed, but he might have had deficits from a myelopathy (spinal cord damage) assuming he didn’t have a fall first and become paralyzed. How many people are out there who are not getting full evaluations because physicians have delegated much of front line care and it isn’t clear to me who might be falling through the cracks? 

At the minimum, when I am given an appointment with a medical practitioner, I want to know before I go who it is. This does not always happen, unless I specifically ask.  Second, if I have seen a midlevel, I want to know whether a physician has signed off on my medical record. Third, I can afford my care, but why is the cost the same with a midlevel as with a board certified specialist, or in one recent case, $100 more for less workup?

Finally, if the electronic health record is too burdensome, some day we are going to have a new health care system. If you are a practitioner and don’t like the time spent on an EHR, assert yourself and design something better. Take back control, like I’m trying to.

PUBLIC SHAMING

March 30, 2019

As soon as I took a step towards the other side of the trail, right behind a crew member starting his chain saw, I knew it was a bad move. Oh well, I jumped quickly to the brush on the other side of the trail just I heard the chain saw roar behind me.  That was stupid, I thought, and I won’t do that again. I was carrying an axe and a hard plastic wedge, and my job was helping the sawyer by being ready to pound the wedge into the top cut to keep it open and keep the saw from binding.  But I should have waited before going to the other side.  

For the second straight week, we were clearing trail out by the Middle Fork Ranger Station near Oakridge.  The Wren Trail was normally a short, easy walk, but scores of large old growth and other trees had been brought down by the winter storm that shut down the county for a week, and the prior week the smaller chain saws used were limited in what could be cleared.

Today, we had cleared a couple of dozen big trees, 2+ feet in diameter, 200+ year-old Western hemlocks with a few Douglas firs and Western red cedars as well.  The trail was open for use again, and we were finishing a spur trail to a nearby road, making several cuts in a downed Douglas fir. It had been a good day, and the eight of us felt good about what we had done.  Nobody got hurt, although one man with whom I was working had a log brush his knee brace.

Before, during, and after. Each area that is cleaned needs to be planned, each log has to have its cut planned, and we need to be better at planning how we will get the logs off the trail. Near Middle Fork Ranger District office, Westfir, Oregon.

Shortly before we drove home, we gathered for a “tailgate session.”  I had been out more than thirty times with this group, and while we did morning tailgate safety sessions, this was the first afternoon one I had encountered. 

One of the two leaders, an experienced man in his 70s, who had spent decades cutting, looked around at all of us.  He looked at me, and then again at others, and I knew what was coming.  He finally looked at me again:

“You,” he said, pointing his finger at me, but not menacingly, “went around the saw as it was being started.  That is the worst possible time to do it.” The sawyer next to him with whom I had been working the whole day nodded agreement.

I don’t know who was looking at me, but I’m sure everyone else was.  I hadn’t been dressed down in public in a long, long time, and it stung.

“As soon as I went, I knew it was wrong,” I stammered.  And I heard again that saws starting up are most unstable.  That I didn’t know.  But I knew I was wrong.

The group discussed a few other things about safety, at least not involving me, but not involving any one individual.  I wasn’t going to say anything more, a decent approach, but I decided I would anyway.

“We need to stop and think before pushing logs off the trail that have just been cut,” I said.  This has been an issue on many of the outings I have been on, and it bothered me.  “I want to help, but if I’m not sure what the plan is, I am not going to hurt myself moving something until I get into position.”

Nobody said much. I’d seen far too many people in the woods push, lift, pull, or otherwise move logs without proper lifting care.  We were all old; sooner or later, bad technique causes problems.  Even good technique can.  I hurt my knee last summer by pushing in a way I thought was appropriate, but with which my knee disagreed.  I said probably the most important thing of all, although I didn’t appreciate it until later, and the others may not have even noticed: “we need to pay as much attention to moving the downed logs as we do to cutting therm.”

The worst thing that happened?  Being called “You.” He didn’t even know my name. I have worked with this man at least a dozen different days in the woods.  I’ve ridden in his vehicle three times 2 hours to a place and 2 hours back.  I talked to him at a benefit for the Crew at a bar because he was standing by himself and I didn’t see anybody else familiar.  OK, some people are bad at names, and I am one, so I wrote my name on the back of my hardhat.  He didn’t take the effort to know whom he was criticizing.

He should have taken me aside right then in the woods and told me why I did what I did was wrong.  That’s how you learn. Then, he could mention it at the tailgate briefing as something he has seen. I would have known it was about me, but I would not have been shamed. Instead, I felt “I’m once again at the bottom of the experience ladder and everybody else knows I’m a screwup and I shouldn’t come out here any more with the group and I just want to go home.”

If nothing else, he could have at least asked my name.

He didn’t.  He dressed me down in public, which my father and the military both taught me you never, ever do.  On board my ship, I heard a lot of yelling behind closed doors, and I saw chastened people afterwards, looking like they had been through a verbal wringer, but they at least had the dignity—yes, the dignity—of knowing that nobody else saw the scene.

Medical training was full of public dressing downs.  Woe to the physician, who, after having been up all or most of the night, didn’t have all the lab tests or a complete differential diagnosis on a patient right at his (usually his) fingertips.  It stings.  It can bring tears.

I saw a public dressing down of one of my classmates at New Mexico State when I was in grad school, and as one not involved in the issue, I felt so uncomfortable that I wanted to be somewhere else—anywhere else—at that time.  It was really ugly, and until this issue in the woods, I had repressed that day some twenty years ago.

When there is a dressing down, here are the reactions:

1. Try to become perfect, even if it is impossible, because perfection avoids mistakes, and mistakes are bad, bad, bad.  Rational? Of course not. But this is not a rational matter; it’s a deeply emotional one.

2.  Defend by attacking.  This same person who didn’t know my name was cutting a log a few weeks ago and not wearing a hard hat.  I deleted the picture I took of him. We don’t want to show that stuff.  We had too many people working in too small of a space today. That was unsafe, and nobody spoke up. We don’t lift properly, as I mentioned earlier. I did at least try to speak up, but it went nowhere. But none of that absolves me from my error, and bringing up examples of other errors is distracting and wrong.

3.  Stick to yourself, stay quiet, stay out of the way.

4.  Hide the error if possible.  A lot of doctors hide errors, because the ultimate dressing down in public—malpractice trial, which I have gone through—is intellectual rape

I’ll still work trails.  I know with whom I will try to work, however, and with whom I will try not to.  I’m a volunteer, after all, and while I’m not experienced at trail work, I’m not a beginner any longer or even a novice.  I go out to be in the woods, try to make current trails accessible again, and do good. I can go alone if I wish.

I’m a natural teacher.  Today, when the young woman at the drug store couldn’t make change properly, and I had to patiently explain the transaction to her two different ways, I did not berate her.  She felt badly enough and apologized for her lack of math.  I told her quietly not to worry about it.  If she’s good, she will worry about it, and she will get better,  but at least it was between me and her.  Nobody else.

BLUE DIAMONDS, WHITE SNOW

March 26, 2019

I had a lot of other things I probably needed to do last Tuesday. There was a trail over in the Drift Creek Wilderness that needed scouting for downed logs, with GPS coordinates, so the trail group, the Scorpions, which I am part of, could tell those who were going to log it out what to expect.  That would still have to wait. I needed to be in the Math Lab at the community college, because it was finals week. 

But I had put off my winter trail checking trip way too long. I am one of the winter trail adopters for snowshoe and cross-country skiing.  I needed to go up into the mountains, hope the snow wasn’t too deep to bury the markers, but deep enough so I could both find and reposition upward trail markers, blue diamonds nailed to trees. I also needed to replace those diamonds that were broken or missing.  I didn’t do it last winter, because the snow wasn’t deep enough.  I had done a pre-season look in October, an 11 mile hike from Gold Lake to the Pacific Crest Trail (PCT), south to the Rosary Lakes, out at Willamette Pass.  But one person can put up a diamond marker on a tree only so far standing on ground, and I was not about to carry a ladder into the woods and stand on it to mark trails.  It is too dangerous, and my wife has regaled me of X-Rays she has seen of people with horrific injuries with the history, “Fell off ladder.” People my age die from minor ladder falls. If any may be considered minor.  Standing on several feet of snow is a good ladder and a lot safer.

I shared this trail duty with another, but it now appears it is my duty alone.  Such happens.  Anyway, I knew what I had to do, so I drove up to Willamette Pass Ski Area on Tuesday, when the place was closed, parked the car on the shoulder of Highway 58, walked past the wet pavement of the parking lot, past a cabin, put on my snowshoes, and headed towards the PCT.  The estimated 10 mile snowshoe would be half on the PCT coming in and out, the rest going up the Tie Trail, nearly a mile long, climbing several hundred feet, connecting the PCT to Tait’s Loop. From Tait’s, I would try to find the PCT again near Maiden Saddle and return via Upper Rosary Lake, back past Middle and Lower Rosary Lakes and out the PCT the way I had come in.  I hoped some trail would be broken with prior tracks, but I wasn’t so sure about the Tie Trail or Tait’s Loop.

Map of part of Willamette Pass. Contours are 40 feet.

 

It was warm, with mostly clear skies and light wind, and I started in a shirt, rain jacket in my day pack and a smaller pack around my waist with a hammer, nails, and five dozen blue diamond markers. The trail initially was broken, snow deep on either side, message board at the trailhead almost buried.  The trail along the PCT parallels the highway for a while, climbing about 150 m or 500 feet in a little more than two miles or about 3 km.  It isn’t difficult, and the last part is almost level.  It’s work but not excessive.  It took me about an hour and change to get to the Tie Trail, where I noted, with a little sinking feeling, no tracks. Perhaps nobody could find the trail: the Tie Trail turns about 150 degrees left and isn’t obvious, so I added two more diamonds to show people where the trail was, and I raised another that was almost at snow level.  The snowpack was slightly above normal, which is reassuring for summer, especially since the valley is in significant drought.  

Blue Diamond in western Hemlock. I try to keep the nails only in the thick bark, not penetrate the cambium.

I started breaking trail in the deep snow, sinking in 1-2 feet and also climbing. The plan was to reposition diamonds higher and make sure from one diamond, one could reasonably be expected to see the next.  This slowed me down, as I had to come up to trees, pull out the hammer, remove nails, remove the diamond and reposition it. Fortunately, most of the diamonds were in good shape and I just had to deal with climbing in soft snow.  The trail went through the woods steeply upward, with a couple of switchbacks, followed by a long gradual uphill to the ridge to Tait’s Loop, adjoining the ski area. 

The diamonds are so necessary, because in the woods in winter, many open paths look like the trail. This diamond needs to be repositioned upwards.

I hadn’t been on Tait’s this winter, but I remembered most of the trail well, and I knew the top part was a lot longer and more difficult than I gave it credit for.  Eventually, I reached the junction at about 6300’ and turned south towards the viewpoint to Lower Rosary Lake, far below me. The Diamonds were in good position, and I didn’t have to fix each one, but if on one side of a tree a diamond was too low, the other side would be, too.

I worked my way around to the center of the loop and had to decide whether to complete the rest of the loop by the ski area and go back down the way I came or continue towards Maiden Saddle.  The head of Winter Trails wanted that area checked as a favor to a friend who was responsible for it. I decided to commit myself to a longer hike and continued along the ridge, found the sign that normally is 12 feet off the ground in summer but now has the top easily reached by my hand.  

I need to go north this year as well, to Maiden Peak Shelter and check those diamonds. Perhaps this weekend.
Lower Rosary Lake from Tait’s Loop

Tait’s Loop from frozen Lower Rosary Lake

The descent was gradual, soft, with my legs sinking in often.  Half way down, I stopped for lunch overlooking the lakes below.  I looked on track for getting done in mid-afternoon and getting home in the early evening.  The grade continued steadily downhill until I saw no more diamonds to follow.  There weren’t any, or maybe there were, but buried.  In any case, I lost the trail.  This has happened to me before here, and I made a note that it will need to be fixed in summer, when the trail is visible and enough markers can be placed high enough to be seen.  I went straight down the hill towards frozen and snow-covered Upper Rosary Lake.  I crossed ski tracks and saw diamonds, but they again disappeared after a short distance.  I continued down further towards the lake and crossed the well-marked main trail.  I was several miles and a few hours into the trip, and I did not have the energy to try climb back up to mark the trail accurately. That would have to wait.  I at least knew where the problem was. 

Continuing in softer snow, the afternoon sun warm, I passed along the east side of each of the three Rosary lakes, left the south end of Lower Rosary Lake, and reached the Tie Trail a half mile later, where I began the loop three hours earlier.  From there, it was back out on a good track, with a gentle descent back to the car.

JUST SAYIN’

March 25, 2019

It’s time again for my annual urology appointment.  Well, more like every 15 months.  After each visit, I am told that they will call me for my annual appointment, but when they call and I set up the time, I hear how busy the doctor is and end up being scheduled about 6 weeks past the year.  It is adding up.  Hope I don’t have a high PSA this time around and hear “You should have been seen sooner.”  Just sayin’.

This time, I got an email telling me I would have a chance to check in online.  If I did that, I could arrive 15 minutes earlier; otherwise I would have to come 30 minutes earlier. I could arrive on time and be just fine, since I will probably have to wait. Last year it was about 45 minutes; again, my physician is very busy.

In any case, I checked in online, which started off quickly by my proving who I was and how I wanted my medical information received. I appreciated that the date of birth could be typed right in and it would appear after the slashes, rather than having to use drop down menus for months (I’m at the bottom), dates (closer to the top), and year (long, long ways down). I also appreciated that I could type my phone number in without parentheses or hyphens. Or country that began with US/Canada and not Afghanistan. I could have done without the comments “we are mandated to do xxx by the federal government.”  Yes, you are, and because my medical profession didn’t pay sufficient attention to privacy, had sloppy record keeping, and medical personnel blabbed about patients in public places. I remember those days.  Just sayin’.

Then I got to the review of systems (ROS), with a surprising limitation of choices.  I have a lot of conditions that I could mention, like my palpitations, but the past year has been good, and I couldn’t state that.  There was no place I saw for sleep issues, and that plus its treatment have direct bearing on one of my urological issues. As a result, my ROS seems nondescript when it isn’t.  “How has your health changed since the last time you were seen here?” Is a much better question, but there are no boxes to check for that.  Just sayin’.

I had to check “None” to each one by hitting a dropdown box, when in fact it would have been faster and saved me time to have to hit one button than to click the drop down menu and hit the None button.  Apparently, however, the default for recreational drug use was “Yes,” and I kept trying to write “None.”  Young people have no problem with these forms because (1) they are used to them or (2) perhaps many are using such drugs.  Not really sure.  Just sayin’.  Anyway, I finally found the “No” button, which could have been more prominent.

The problem with these sorts of ROS is that nobody learns much from them.  There’s no time. But I have long learned that coding is important in medical practices these days, and a big part of getting more money is having a ROS documented.  I know, because ROS was never much part of a dictated H&P (History and Physical) after physicians were in practice until it was reimbursed at a higher code back in the late ‘80s.  Then the (hospital/doctor’s offices) wanted it.  By having the ROS filled out beforehand, one can save 5-10 minutes of often boring questioning, maybe more, upcode and bill more, without having to do anything. Everybody is busy. 

Interestingly, I noted that there were no questions about sexual problems, and this is a urology office.  Sexual function and urology go together. They do in embryology and they do in adulthood. Now, maybe I didn’t look carefully enough, but hey, I’m the patient, so if I have trouble, someone else may, too. After all, many patients who see urologists are old.  Then again, sexual dysfunction may not be high on the radar. Be glad you are alive, old timer. Don’t push your luck. Just sayin’.

At the end, after requiring my agreement to release of privacy information (if I wanted to be seen), I was taken to a form for release of genetic code for research.  This stopped me for a minute.  I don’t have a problem with research, but I have a sense—not totally rational perhaps, but it’s still my sense—that there are privacy issues and someone’s getting free material from me without donor recompense.  I ended up signing it anyway and moved on to the last part, the use of material by PR (not their real name), the company that owned the checkin software.  I started to copy and paste the material into “Pages” to do a quick word count (just curious) when I saw the word “advertising.”  

Whoa.  What’s this?

The company would then be able to send me marketing materials (that’s advertising.)  Well, I checked the definite NO on the form, but I wonder how many my age just checked it YES, because they felt they had to. I looked up PR online and learned that it was a software company.  Going further,  I looked at Web pages that didn’t have the name of the company and might give me a more unbiased look at who they were.

Many of the responses in a survey were from happy medical office workers.  Lot of 5s out there and glowing testimonials.  But I looked at the “cons” and read that young people liked this approach, whereas older people (like me) had more trouble (like trying to check “No” on substance abuse).  When I hit the worst evaluations, there were comments about this program not working in their office and difficulty severing a relationship with the company. 

What surprised me, besides my realization yes, I really am old, is why this urology practice would use software that the elderly didn’t like.  As I said, every year I see a lot of real old people in there from my vantage, and if I am having trouble, I can only imagine what difficulties they are having.  Except not sexual ones, judging by the lack of pertinent questions.  Glad we’re still here.  Just sayin’.

Last year, in addition to seeing the doctor, whom I do like and who is good, he had a scribe, so he could actually look at me and not the screen. It’s disquieting to have a doctor focused on the screen and not me.  The physician is missing something, no matter what he/she thinks.   Some look at a patient because they were told that eye contact mattered and they needed to do it so that the patient would check the right button in the inevitable survey afterwards. I always looked at a patient, because in neurology looking is how we made the diagnosis.  I still quietly diagnose people in public.  

Those of us old-fashioned docs used to ask nurses, “Does the patient look sick because a good nurse could answer it quickly, accurately and it mattered.  The scribe took away some of the privacy, and these days privacy is disappearing about as quickly as wilderness.  It’s a little strange to be having a prostate exam with a young woman on the other side of a thin curtain.  At least I find it strange.  Could she be in another room? I think it would help.  Just sayin.’

Anyway, the presenter of a scribe takes away privacy.  Yeah, yeah, I know.  It will be kept private.  

Like Facebook.

I REALLY SHOULD HAVE STAYED HOME

December 8, 2017

I really should have stayed home that Tuesday evening and not gone to the German Stammtisch at Track Town Pizza.  I go there most Tuesdays to practice my German, to listen, speak, and to talk to people there.  It’s good to get out.  I only stay an hour, because the place has low ceilings, serves alcohol, and gets noisy fast, so that I have difficulty enough understanding English, let alone German.

Last Tuesday, I got into a political argument, first one in a long time.  It was my own fault.  Oh, I can blame the other individual, but I shouldn’t have taken the bait.  Unfortunately, however, a lot of things that have stewed inside me for some time came to the surface.

Normally, I try to steer clear of these arguments, with the exception of climate change, where I immediately put out my four rules: no pejorative attacks, required p-value, confidence intervals or margin of error, what happens if one side is wrong, and verifiable predictions locally, nationally, and globally.  That has always ended the discussion.  I need that approach for politics, although I admit difficulty these days in avoiding pejorative attacks, since my default mode when I get angry is a severe case of sarcasm.  It’s one of my huge flaws.

Anyway, the initial trigger was discussion about an upcoming lecture being given by a German official about immigration.  The individual with whom I was talking—an immigrant himself, I think—was saying how the speaker from Germany was lying.  I had no facts, so I let it go. I’m a grandson of an Irish immigrant, and I believe are that if more countries were problem solvers, rather than problem causers, there would be fewer immigrants. But the fundamental cause of immigration woes is overpopulation,  and unless we control population, immigration, with its attendant problems, will increase.  There are two major realities: one, we can’t grow indefinitely and two, we must control our numbers.  Unfortunately, population control is not on the agenda of The Other Side—or for much of my side, either for that matter.  A lady recently profiled in Sierra, the Sierra Club magazine, had three children.  I almost wrote a letter about it then thought better.

We then got into a discussion of weapons, after the individual mentioned a recently deceased friend of his who had several machine guns and a half million rounds of ammunition in his home.  I was shaming myself silently for being secretly glad his friend—63, massively overweight—died suddenly at home. Half a million rounds of ammo and at least one machine gun.  Wow.  Another listening to our conversation asked why the dead man—or anybody else—needed a machine gun.  We got the usual Second Amendment response, and that is where I started getting angry.  I wasn’t going to argue the wording, but I wagged my finger at him—something I inherited from my father—and said “I hope some day you feel the same kind of pain those who have lost people to gun violence feel.”

I’m not a Christian, and while I don’t have to be a jerk, I don’t have to be nice, either.

I’m not honestly sure what else was discussed, but the individual blamed Obama for the drug trade in this country. I was a bit stunned, saying that we have had a war on drugs that began when Mr. Obama was a child, and that he hardly was the person responsible.  I mentioned the Bush years, which seem to have vanished into the murky morass of 21st century history so far, the two wars and one recession have been blamed mostly on his successor, but while the man said he didn’t like Bush, he had absolutely no use for the Democrats.  Social programs, he said.  That was the reason.  So I asked him what sorts of social programs were a problem.  Unlike Mr. Obama, who is a centrist, or Ms. Clinton, who is center-right, I’m a liberal, but I can find wrong with some social programs.  I couldn’t get an answer, and as angrier I became, the quieter my voice was. I kept asking which social programs he was against.  I could have said that Social Security should have means testing.  I certainly would limit the tax deduction for children, in a somewhat feeble attempt to try to decrease population, and limit the mortgage deduction to $500,000.  This man couldn’t come up with anything, despite my quietly asking him “Which social programs?” five times.  All he could come up with was disability: “I see people getting disability who are better off than I am.”  OK.  That’s an issue, but it is hardly budget busting, and are we going to end disability payments because some cheat? The answer to some is yes. The Other Side wants to restrict voting because some cheat, which I believe was fewer than 10 in the last election, the first one’s documented being a Republican.  I am ignoring the almost certainty of one party’s involving the Russians and the definitive asking by the nominee for the Russians to publish every email they had.  That’s illegal and treason.

I didn’t mention my relief that a person with a half million rounds of ammunition was dead. When the individual stated with some outrage that the ATF (Alcohol, Tobacco, and Firearms) was in the house and planned to destroy the weapons, not give them to the dead man’s heirs, I didn’t know the law, so I kept quiet.  Destroying them sounded like a good idea, like beating swords into plowshares, but I’m no expert on Isaiah.

I remember that during a break in the arguing, the other man said that he wished the conversation hadn’t gone on because “I don’t want you to think badly of me.”

“I already do,” I replied.  And I suddenly got up and left, walking out, not turning back to look.  I cared not a whit for what he thought about me.

Several days later, it’s difficult for me to remember what it really was that pissed me off so much, and I’m ashamed I spent so much anger accomplishing almost nothing.

I should have quietly exited the conversation, rather than getting into a pissing contest with a skunk.  It’s difficult these days to read the news, see the direction of the country, and not be worried, lose sleep at night (unless this is age), and feel powerless to do much about it.  I’m frankly weary of dozens of emails clamoring for money for some candidate, promises to impeach (which doesn’t solve the problem; conviction is then necessary, and I also know who the second, third, and fourth in line people are), and the continuous surprise that things turned out the way they did. I find it stressful that I wish for bad things to happen climatically so I can say “I told you so,” and I hope those who voted for this government get hurt.  That’s petty, considering these people won’t vote Democratic even if their candidate is a pedophile or groped women.  We already know that.

I walked outside into the pouring rain.  Wonderful. I love the rain.

NIGHTSTANDS AND CLOSETS

April 3, 2015

About four years ago, I came within six inches of never being able to hike again.  I was at a holiday party given by an acquaintance who was a retired field grade officer in the Air Force.  We had a mutual interest in astronomy—he became an amateur-professional whereas I remained an amateur.  Indeed, he once told me that my eclipse chasing wasn’t really astronomy, so I stopped mentioning it to him.  Then again, back in late 1991, he said the annular eclipse of 4 January 1992, visible from San Diego, was “no big deal.”

Annular solar eclipse 4 January 1992.  It ended before it reached the coast, but from a 300 m high hill, we could see well out into the ocean.  Two hours later, it was pouring rain.

Annular solar eclipse 4 January 1992. It ended before it reached the coast, but from a 300 m high hill, we could see well out into the ocean. Two hours later, it was pouring rain.

Seeing the “ring of fire,” the Moon inside the Sun, set into the ocean, ranks as one of the best natural views I’ve ever seen.  He missed it.  My acquaintance had made some public statements that offended the fringe who believed in odd celestial occurrences.  For that, he told me at the party that he had received death threats.

“Want to see my weapon collection?” he asked.

I didn’t want to, since weapons bother me.  When my father died, we found a handgun in his nightstand and couldn’t get rid of it fast enough.  Fortunately, we knew a deputy sheriff.  My host showed me a laser guided gun on his nightstand, ready to fire in case anybody broke in and tried to kill him.  Wow.  I looked at the gun and saw instant death, oblivion, cessation of existence. Then he showed me his closet with as many weapons as clothes, several different kinds of firearms, any of which probably could have taken out the neighborhood, had he been crazy.  At that point, a samurai sword, unsheathed, dropped from a hanger on to the floor.

Six inches from my left foot.

This is a smart person, but where were the safety checks?  No, this wasn’t a gun, “only” a sword, that could also kill, and a lot faster, had it been grabbed, than a nearby firearm. Had it been a loaded gun and discharged, I could have died instantly.  I never went to another party there again.  It just freaked me out.

Gabby Giffords, who four years ago was shot in the left parietal lobe by a crazy gunman, 4 miles from where I lived, at a store where I almost went that day, was recently at the Capitol to support a bill expanding background checks before firearms are bought.  Such checks are espoused by an overwhelming majority of men, women, Republicans, Democrats, and firearm owners themselves.

The NRA wasted no time tweeting how Giffords’ own shooter passed a background check, omitting the fact that the individual complained about the difficulty he had.  The NRA proffered other examples where background checks were done and firearms were later used in homicides.  That’s like saying somebody in an accident wearing a seat belt died, so we shouldn’t wear seat belts.

We have gun shows where people purchase firearms with no background checks at all.  Video recordings are amazing.  They show things occurring that people still deny, be it buying a gun at a gun show and leaving, without any checks, to denying that one ever said Iraq clearly had weapons of mass destruction.

Will background checks prevent all murders?  Of course not.  Will they make them fewer?  I believe they will, a verifiable prediction.  If I am correct, would not the prevention of one murder be a good thing?  Exactly how are people’s rights to own a firearm infringed?  We don’t have unbridled freedom of speech; why should we have unbridled right to bear arms?

I made the mistake of reading some of the comments at the end of the article.  One guy basically swore at Ms. Giffords; another, while extolling her courage, wanted to make sure his right to protect his family was not infringed.

Does this man think his family is under siege by robbers just waiting to kill him?  Does he not know that the presence of a firearm in a house nearly doubles the likelihood of a mortality there?  It increases the likelihood of a suicide of a man living there thirty-fold.  Could a gun protect him?  Sure.  But a bigger problem is the number of deaths in this country from domestic violence.  Three women a day die here on average from domestic violence. Want to end it?  Make it a lot more difficult for stalkers and people within 2 years of a divorce to own firearms. Why two years?  Not sure, frankly.  It seems like two years is enough time to get over the fact that a relationship is over.  If I am wrong, that could be changed.

Exactly how many people need firearms to protect their families?  Truthfully, I DON’T KNOW.  One of the reasons I don’t is that we don’t have research on this and other issues dealing with gun violence, because the National Rifle (read: Gun) Association has prevailed upon Congress not to allow this to be done by the CDC.  If gun violence isn’t a disease that needs to be controlled, then I’m missing something.  Over ten thousand people a year in this country die from it, triple that if you count suicides; seven times that number are injured.  Had Ebola killed this many, we would have shut the country down.

I’m worried, too, not of being gunned down, but that my car will be vandalized if I put a sticker on it saying “Americans for Responsible Solutions.”  Sam Brownback has signed into law that allows Kansans to carry concealed firearms without a permit and without requiring a gun safety course.  There is a sense that Kansans will do the right thing, and they don’t need the government to tell them how much training or responsibility they need.  There won’t be a blood bath in the streets, they say, this isn’t the Wild West.  Perhaps they are right.  What if they aren’t?  Where is the evidence?  Who is counting?

Each day I read of people gunned down, of children taking guns, pulling the trigger, killing their mother, sibling, friend, or themselves.  I’m not scared I will encounter a situation like that; although it is certainly possible, it is improbable. As one who thinks firearms need to be better controlled, I am unpopular, at least among a vocal, scared, hateful group, not a majority, who nevertheless control the agenda for firearms.

Guns are too slow and too quick.  If you are a teacher with one in your desk drawer, and a mass shooting breaks out, you may well be gunned down before you get it.  If you have one available, and you shoot at what appears to be an attacker, but who isn’t, which almost happened that day in Tucson, then it’s too quick, too final.

After 9/11, we talked about arming pilots.  How does that sound now?

PASSING IN A SCHOOL ZONE

March 10, 2015

The sign said “20 mph between 7 and 5 on school days.”  Oregon has two types of 20 mph school zones: that and “20 mph when children are present.”  I was doing 20, when a guy behind me pulled into the center turn lane, accelerated, passed, pulled in, driving far more than the 35 mph speed limit after the zone.

I caught him at the next light.  So, to save a few seconds, the guy broke a few laws, wasted gas and brakes.  For nothing.

**********************************

“Why didn’t you call a neurosurgeon?” The plaintiff’s lawyer asked me in a deposition, back in 1978.

“I and my attending did, Sir,” I replied.

“Why didn’t you hurry and do it sooner?  The patient might not have been paralyzed.”

“He already was when I first saw him, Sir.”

The patient, with ankylosing spondylitis (AK), a bad disease that fuses bones of the spine, had fallen and had cracked his spine.  Unfortunately, an orthopedist tried to move the neck, producing spinal cord injury and partial paralysis.  I resented being blamed for the catastrophic outcome, and it would be the first of a long number of bad encounters I had with the legal profession.

Technology now allows non-radiologists to view many images before the radiologist.  This increase in speed of transmitting information occasionally comes with a cost.  Recently, an individual with AK and a neck injury was felt to have a normal C-spine X-Ray, according to a physician’s reading in a trauma center. The reading was wrong but fortunately did not cause a similar catastrophe.  Radiologists should read these images before anybody moves the spine of a patient with AK.  I’d make it mandatory.  It doesn’t guarantee a good outcome, but it improves the probability of such.

*************************************

A Chance Fracture has nothing to do with luck.  Or maybe it does.  Formerly called seatbelt fractures, before shoulder harnesses, they occur with violent forward flexion of the thoracolumbar spine.  The anterior or front part of the vertebra flexes and compresses, the posterior elements fracture.  It is highly unstable, and the proximity of the fracture to the nerves in the spinal canal means paraplegia may occur.

A patient was seen after an automobile accident, and a physician noted free air under the diaphragm on one image.  This means a perforated viscus, usually the bowel.  The patient was quickly taken to the operating room, for speed matters, and the “bowel was run,” meaning that all of it was checked.  The radiologist, in the meantime, looked at the images, noting no free air but saying there was an Chance fracture.

Oops.  In 100 yards, the speed limit will be 35. Did you have to pass?

The patient now has an abdominal scar, is at increased chance for adhesions and a bowel obstruction as a result, and was fortunate not to be paralyzed after having been moved.  Waiting a few minutes for the radiologist’s reading would have avoided an operation.  Free air requires immediate attention, but surgery may be delayed until the diagnosis is clear.

*****************************************

A third patient had a dislocation of the hip, a bad injury, and was taken to the OR before the radiologist reported a clot in the iliac vein.  Such clots are a risk for pulmonary emboli and complicate surgery, something the surgeon must know pre-operatively.  There was time to think; fifteen minutes wouldn’t adversely have affected the outcome.   Like the guy passing me, hurrying may save time, waste time, or cause a bad accident.

I don’t practice any more.  I wasn’t a trauma doctor, but as a neurologist I saw plenty of trauma long before we had Level 1 centers.  I am out of date.  But I know the ABCs, airway, breathing and circulation, which were and are essential to deal with immediate survival.  Here, seconds and minutes count.  Otherwise, I palpated the entire patient, looking for injuries that weren’t obvious, but might become significant problems.   It’s easy to see an obviously fractured femur and immediately want to fix it.  A wise radiologist said, “The first thing you must do in an emergency is take your own pulse.”  By that, he meant to stop and think for a few seconds.  If you don’t have a few seconds, it’s probably too late.

Time.  It is about time.  Knowing how much time one has matters.  Knowing how much time one has to think matters more.  Time.  Is it worth doing 45 in a 35 zone?

Technology has revolutionized medicine.  Improved communication would as well, if we actually did it.  If several people with significant injuries arrive at a trauma center, they must be triaged.  Some need help more quickly than others.  For some, it is sadly too late.  Many may require the same test; the order in which they get it must be established.  Communication means telling the radiologist the history of the patient, what the clinical concerns are.  It improves the reading of the image.

Ask a radiologist sometime how good clinical histories are.

Today, we do whole body scans.  These take time to perform, valuable time. Taking extra minutes to scan the entire body may delay doing an important test on a second patient. These scans deliver much ionizing radiation and are expensive.  Neither of the latter two is an immediate concern, but they are issues.  Radiologists read hundreds of images quickly, and that requires…..time.  Anything that limits the number of scans is good.  Clinical evaluation does just that.  Patients with free air under the diaphragm likely have a rigid abdomen.  Chance fractures produce severe back pain.  This information helps the radiologist immensely.

When I was responsible for caring for many sick patients, I triaged them, trying to make best use of time, an important commodity in my life.  I needed time to eat, sleep, think, see patients, and summarize my thoughts.  I had only so much of time, and only I could prioritize it….until the day came when I realized I could no longer fit what was expected into what time I had.  Hurry is both dangerous and stressful.  Kids suddenly jump out into the street.

Television makes it appear that speed saves save thousands of lives, that everything must be done in a hurry, and that death is prevented with seconds to spare.  That simply isn’t true.  Time is important, because waiting can be deadly.  But there must be time to think, to reason, and to plan approaches, too.  Or people will die.  We all make mistakes.  We can prevent many with better standardization, lessening fatigue, fewer interruptions, ordering only what needs to be ordered, giving information to radiologists, allowing them time to read images before people are rushed to surgery.

Once one is beyond the ABCs of resuscitation, there is time to think and plan care.  That time must be used.

The next light will likely be red, anyway.

MACK AND JACK

March 4, 2015

Former Arizona Sheriff Richard Mack is asking strangers online to pay medical bills he and his wife have incurred.  The Constitutional Sheriffs and Peace Officers Association, which Mack founded, is paying some of them.  Mack is LDS;  I was surprised that the Church wasn’t passing the hat.

I actually wish Mr. Mack good health, hoping he gets coverage under the Affordable Care Act, which he was ardently against.  I guess that makes me a liberal, whom Mr. Mack detests, because I think part of my job as a citizen is to help other citizens.  If my taxes support people on Medicare, for which Mr. Mack will be eligible in two years, assuming the program isn’t gutted by his fellow Libertarians and Republicans, then so be it.  Medicare is a good program.  It helps the elderly.  Some in Congress think that is a free ride.  Well, all Americans get a free ride, be they Ted Cruz, Mitch McConnell, or Mike Smith.  My college education was subsidized, I get more from SSI than I paid in, and I can access for free things the government requires be open source.  Oh, I had to give a couple of years of my life to the military, but that is national service and something people used to do.  Ted and Mitch did not serve. Besides, I got paid for it.  The idea that successful folks are self-made, without help, guys like Jack Welch for example, is pure baloney.  We all benefit from being Americans and from what our government does.  Research that improves medical care is tax supported, roads, infrastructure, the National Weather Service and Hurricane Center, the Coast Guard, plows during snowstorms, FEMA, all benefit us.

Passing the hat was once helpful when medicine couldn’t do much, or if somebody’s barn burned down.  It doesn’t cut it today, when a house is lost, a child has leukemia, or if you are 62, like Mr. Mack, and have had a heart attack.  After passing the hat a few times, there isn’t much money; people can’t chip in that every time there is another needy soul.  That is sort of why we have the Affordable Care Act, which covers people for whom the hat isn’t large enough to hold say $10,000, which isn’t much for a hospital stay.  Most of us don’t have that kind of money lying around.  Jack Welch does.  He got about $400 million when he retired from GE, after cutting 100K jobs and research.  He’s on his third wife, by the way, but at 79, his time has passed.  He won’t be around to see what his denial of climate change has done.

Back to Mack.  He supported Cliven Bundy, the rancher who refused to pay for grazing his cattle on public (that’s my and your) land at $1.35 per animal per month eating an average of 780 pounds of foliage, and got away with it, because to have thrown him off would have been akin to the attack at Waco in 1993.  Mack got the Supreme Court to weaken the Brady Gun Bill, and he ran for a Congressional seat, getting 11,000 votes in the primary.  That’s about 10,950 more votes than I would have gotten had I run in a primary in Arizona.  I got 50 votes in the last election I ran for, Secretary of the Arizona Medical Association, which I lost.  I wasn’t too popular in the medical community.  I told the truth.

I wish Mr. Mack good health, because ill health sucks.  I haven’t had a heart attack, but I have been very ill, and it isn’t fun.  Mack doesn’t deserve it.  Nobody does.  He deserves to have insurance, and when I supported the ACA, I hoped that all uninsured would be covered.  Many of those I may not have liked, but they deserved coverage.  Frankly, single payer, like Medicare, would have been simpler, but it was never put on the table, which to this liberal is unfathomable.

Some would say that wishing good health on somebody who supports views you detest is Christian.  Or LDS.  Well, I’m neither, and I can’t stand the latter, which has probably made a bigger mess of Arizona than other single group I can name, since their influence has packed the legislature and certainly helped Jeff Flake, a nondescript House member, win a Senate seat over Richard Carmona, a Vietnam Veteran and former Surgeon General.

My feeling about Mack is not dissimilar to that towards a woman who posted on Facebook “we ought to use the guns we have to shoot liberals.”  I pointed out that I was a liberal, a veteran, probably paid more taxes than she and her husband made, and volunteered in my community.  She apologized, one of the few I have ever received in my life, saying she and her husband had fallen on hard times when he lost his job and got sick.  The only thing they really wanted, aside from being out of debt, was to be able to hunt deer for meat they needed, without people’s deliberately scaring off the deer. I felt a little badly being right with my financial assessment. It was a cheap shot.

I’ve been a Life Member of the Sierra Club since 1983, but I wished her well, both with hunting and with her husband’s problems. I don’t believe in hunting, but hunting for food, when one needs to eat, and has no other choice, is not a sin.  They’ve been dealt bad cards, and while we can’t help everybody live great lives, we ought to help people get off the floor.  That’s what this liberal believes.

Many things I support help people, and my liking them is not a precondition.  It is not my place to judge whether only nice people get help; every citizen deserves to have affordable medical care and education.  They don’t deserve a free ride through life, but education is essential to our success as a country, and medical care costs are one of the biggest reasons people become bankrupt.

Don’t get me wrong.  I worked hard to get what I got.  In high school, I studied when other kids partied.  Did the same in college.  Worked damn hard in medical school and post-graduate, often being on call every other night. Served two years in the Navy on a ship, so I started my medical practice when I was 31, after many had been making good money for a decade.  I didn’t go abroad in high school or college.  Would have been drafted.  I’ve done a lot in my life, I worked hard to get it, but I got a huge amount of help along the way, without which I wouldn’t have gone anywhere.  I’m grateful.

It’s time to give back.  Way past time, so others may get the same shot at success I’ve had.  But I won’t donate to Mr. Mack.  He deserves medical insurance, and I’ll vote for that.

Maybe Jack Welch will help out.  Or his second wife.

She had a good pre-nup.  Does my heart good.

“IF I AM STILL AROUND”

March 2, 2015

I just know the man was younger than I.

And early last summer, he was healthy, or at least so he thought.

Today, I read his obituary in the paper.  He had been diagnosed with “brain cancer” (a glioblastoma, likely) six months earlier.

It gave me a moderate jolt.  These sorts of things do.

There is death, and there is death.  For those who are demented, death is a release for them and their families.  It is sad, but it is a release.  Society often doesn’t allow us to say that, but many of us think it.  When my mother-in-law died at 94, one niece cried for hours.  My wife and I just said, “It’s finally over.”  My mother-in-law had been widowed twenty years earlier, was never the same, moved out of her house to assisted living 8 years later, had become slowly demented and had been ready for death for years.

I have seen too many who did everything they could to forestall death, when it was not only going to be the outcome, it needed to be the outcome.  I wasn’t popular, but I had the respect of nurses who dealt with these issues first hand.  When I practiced, I once had eight dying patients simultaneously in an ICU.  I had to deal with eight families, each of whom had members who were dealing with a family death for the first time.  I don’t remember what I got paid for it; suffice it to say that my total bills for the entire 8 were less than an average inpatient surgery at the time.  Surgery takes skill; dealing with death?  Well, that is another story.  That’s just talking to patients or families, not taking a knife and curing them.  Talk is cheap, and talking about death isn’t paid for at all.  Remember Death Panels?  That was just paying for the discussion with people about how they wanted to die.  You’d think from the uproar that elderly people had never thought about the concept before.  I submit talking about death is far more important ultimately than a good deal of procedures Medicare does pay for.  Perhaps if it were reimbursed better, the discussions would be better, but I am out of date.

Here in Oregon, people who are competent and terminal can choose the time of their death, not passing, for passing is a euphemism that makes us think that the non-existence of a former sentient being is something other than non-existence.  About seventy-five people choose that option here every year, not many.  These individuals know full well what they are doing.  They know they are dying soon, and they don’t wish to go through the indignity, often painful, to reach the end result—death.  Some use “assisted suicide” to describe this law, but suicide has a different connotation in our language, and “planned death” is a better term.  The individual is dying soon from a disease, not a medication, and they don’t wish to go through the whole disease process to the bitter end.  There are strict controls, and people die when they are ready, having had for some time the knowledge that they could choose or not to choose to use the drugs that would allow them to die.  A third never use the drugs.

A death from a bad disease in a younger person is a particularly bad tragedy, even if it is were not preventable.  It is a message to those of us who hear about it to be sure we are doing what we want with our lives.  It is a message to end estrangements, if possible, to fight only those battles that are meaningful, to leave behind something good, to live and to be able to say to yourself or even aloud, “I am alive!!!!”

I don’t live in a perpetual state of angst about death, but I find myself discussing events in the next 1-2 decades with the caveat, “If I am still around.”  Mind you, accidents, which can occur at any age, can cause sudden, unexpected deaths.  In one’s 60s, however, there are a lot more things that can kill.  Pneumonia is suddenly not just a minor inconvenience; it is life-threatening.  One nurse told me a two years ago that a cardio-thoracic surgeon we both knew developed leukemia at age 60 and was dead 6 weeks later.  I probably had my mouth open for a couple of minutes.  Suddenly, the problems of the world don’t seem so pressing.  Indeed, Oliver Sacks, who recently admitted he has cancer metastatic to the liver, has stated just that.  He no longer watches the news.  I can’t say I blame him.  I don’t watch it much, either.  I try to deal with the things I can control, not worrying about the many over which I can’t control.  I wish I could stop worrying about the weather and climate change.  I can’t change it, but it still hurts to see it happening.

That means I support the Humane Society, but I turn off commercials and don’t look at posts that show animal abuse.  I simply do not have the time, resources or energy to deal with every needy individual in the world.  Further, the sheer volume of these requests overwhelms me and shuts me down.  I feel like a failure that I can’t fix the world. I am not going to try, and if that makes me a bad person, so be it.  I try to choose my battles, decide where my money, time, effort should go, and am glad I am in a position to do all of these.  I have my own list of things to do; another list, much shorter, are those few things I have done in life that I believe have defined me as a person who existed and which have mattered the most.  The first list is written down, not ordered.  I discuss it should people ask and make it a point to do the things on it when I can.  The second is far more private, and it is very much ordered.  I am deeply clear what those items are.  Others may have seen me as a different person, but this list describes how I see myself.

I don’t know how much time I have.  I just know that every year needs to count for something, and something on one of those two lists needs to be part of every year.

CHEWING AN APPLE

February 23, 2015

Yesterday, while looking for a pair of walking shoes, I was helped by a saleswoman who chewed an apple the whole time I was there.  I know people often need to eat while working.  I did it for years.  But eating in front of a customer one is helping seems rude.  I wondered about her education.  It was a good day to wonder, for the Sunday paper had reported that Lane Community College received a “scathing report” during their accreditation.  They are accredited, but there is a lot of work that must be done in the near future; a repeat visit is planned.

There are issues that clearly relate to Lane, regarding course structure, how students are evaluated, and a need to establish clearer goals.  There are other issues, however, not mentioned in the article, which I think need to be discussed.  I wrote a letter to the paper, but after finishing realized I had already used my allotted one letter per calendar month.

I am not an educator, only the son of two.  I have, however, taught at a community college and at a for-profit university, leaving the latter, because I thought it intellectually dishonest to pass students in statistics when they had neither the necessary math skills nor adequate time to learn it.  Not understanding the slope of a line makes linear regression impossible to learn. 6 E-5 on a calculator is not 6 but 0.00006.

I volunteer at Lane twice weekly tutoring math.  Yes, I eat lunch while there, but I put food away if a student needs help. In Arizona, I volunteered in 3 high schools for 9 years, eventually becoming a substitute teacher, because I wasn’t utilized enough as a volunteer.  I ate on the job there, too, and I barely had time to use the bathroom.  We need volunteers in the schools, but they must be kept busy.  Establishing such a system should be a national priority.

At Pima CC in Tucson, 80% of the incoming students flunked the math placement exam.  In a high school in an affluent district, I spent two years helping students do “accelerated math.”  The euphemism was an attempt to help 10th graders, with elementary school math knowledge, reach standards allowing them to graduate from high school, standards that have since been removed, after first being watered down.  We want math fluency; we just don’t want to hold students back from graduating if they don’t have it.  One may argue the test wasn’t good, but at least there was a way to evaluate students.  Now there is none.

The students I taught needed multiplication tables beside them, which I think should be known by everybody reaching junior high school, let alone 10th grade. I think students should know 8 x 6 or how to divide 3 into 12 without using a calculator.  I’m not exaggerating.  Each had been passed up the line despite their not knowing basic arithmetic.  They got “participation points,” “trying hard” was important, and some of their parents demanded they be allowed to finish high school with their peers who did know these basics.  Watch Suze Orman sometime, and it becomes clear what happens when people don’t understand finance.

Community colleges have become de facto high school finishing institutions.  I don’t know whether community colleges pass students to the next level—the workplace or a 4 year college—with the skills they need, like making basic change at a cash register.

Or not chewing on an apple when one is helping a customer.

I have three fundamental questions:  1.  What are we trying to do?  2.  How will we know we did it?  3.  What changes can we make that will solve the problem?

Funding tied to number of degrees awarded increases pressure to award degrees.  How do we know if the degree is worthwhile?  One can pass students up the line, but eventually I want a doctor, a mechanic, a pilot, or a computer specialist who is competent.  The piper must be paid.  Competence must be definable and proven.

It includes not chewing apples in front of customers.

I don’t believe a four or even a two year stint in higher education is necessary for all.  Many important jobs in our service economy don’t require college.  Education’s primary role might begin by teaching early and often that complex 21st century problems are not addressed by catchy phrases.  We need to grant meaningful degrees, not just count them, teach the myriad skills required today, pay for them, and keep education affordable.  Climate change, ocean acidification, immigration, religious fundamentalism, North Korea, Cuba, Iran, competition, environmental degradation, defense, can’t be addressed by “America first,” “boots on the ground,” “I’m not a scientist,” “deport all of them,” “de-regulate,”  “let the market do it,” or “allow parents to decide.”  None of these and other issues have clear answers.

We need to determine what courses are needed for today’s workforce and for those jobs we believe we will have in the future.  In 2045, people will be doing work that today not only doesn’t exist, we can’t even imagine what it will be.  Streaming video online, wi-fi and smart phones weren’t things I thought about in 1985.  Indeed, the words “streaming” “wi-fi,” and “online” didn’t exist, smart belonged with people, and video was defined in millimeters and called “film”.

How we certify students needs to be changed.  We need a required, sensibly structured way to state that an individual is prepared for the next step. These changes will be painful to higher education.  We have to pay for this as students and as taxpayers.  The debt load is burdensome; people need to learn what is necessary for a skill, which may not require 4 years, or even 2.  Stampers don’t need to know Chaucer, not if it is part of their $50,000 student debt at graduation, but they need to know enough math to do finance, enough English to communicate, and enough science, history and geography to be able to vote intelligently.  Professional golf management as a major once sounded like a joke, but given the popularity of golf, I’ve reconsidered my position.  By the way, learning to reconsider one’s position on a matter should be taught, too.

What are we trying to do?  Have an educated populace in the 21st century.  What is an educated populace?  I don’t know.  I offer my thoughts, and if our country were a place where we could discuss complexity with civility, not with talking points and shouting, we might be able to answer this question better.

How will we know we have done it?  We need better measurements than we have, ones that will tell us the bitter truth, which we all know exists.  We have millions of poorly educated citizens.  Let’s neither allow gaming of the system nor get hung up upon punishing schools.  The solution will be expensive, requiring money, volunteers, good ideas, but most importantly evaluating students honestly. It will be painful.  The truth usually is. We need multiple career pathways to accommodate variability in learning and intelligence.

How do we move forward?  Ask the right questions. Then answer them.  Honestly.