Archive for the ‘GENERAL STUFF’ Category

SCHÖNER TOD AND DEATH WITH DIGNITY

February 11, 2015

A friend of mine in another state told us his mother died about a month ago.  I met his mother once, and found her a lovely, friendly person.  But we all get old, and her old age was complicated by strokes and gradual deterioration.  For those who say age is just a number, it can be a crappy number.  She was a widow, too.  A great majority women over 85 are unmarried; half of men.  Just a number?  No, real numbers.  Sad facts.

When she went to hospice, after another stroke, she developed disordered breathing, hyperventilation, which could have been due to the stroke or early pneumonia.  To me, it really didn’t matter, because once a person is in hospice, they are to be kept comfortable until they die.  That may require morphine.  Yes, morphine, addicting morphine that slows down breathing, suppresses coughing, and might actually hasten death.

Can’t have that, say some.

Admittedly, the feds have a schizophrenic approach to pain management, because the medical profession failed to manage pain adequately at both ends of the spectrum.  We gave too much pain medicine to the wrong people for whom it was not helpful and addicting, and we under-treated others, who needed more analgesia than they received.  It is entirely possible one day to be in a hospital, where smileys for amount of pain are measured, and 1 smiley is good.  A day later, one may be out of the hospital and pain medication strictly controlled so he doesn’t become a medication abuser. I may exaggerate, but not much.

Pain or agitation control, when a person is dying, should be easy.  You give whatever it takes to control it.  This lady, mother, grandmother, wife, was dying.  Her life was ending.  She, like my late mother-in-law, lived far too long.  Yes, that happens to many people.  Hey, it’s just a number, right?  Life is sooooo precious, until when one is ready to die and won’t.  Sort of like Dustin Hoffman in “Little Big Man.”  But this is real.

Or won’t be allowed to, naturally.  We say that not treating a pneumonia is “playing God,” but we resuscitate people who don’t want to be resuscitated.  I’m not a believer, but if I were, I would say that is much closer to “playing God.”  The Bible and the Qu’ran don’t say 300 joules to shock the heart, when a person with dementia suddenly has a heart arrhythmia.  My friend’s mother would have liked to have lived a long, healthy life, but the second adjective was not to be.  She was ready to die.  She had nothing left to live for.

I hope I am that brave, should I reach that situation.

I hope I don’t end up in a hospice where morphine is “metered out,” in small amounts, because someone fears they might be accused of killing somebody, by making them comfortable in their final hours, even if the final hours were shortened.  If that is wrong, then the world is wrong. Fear of the patient’s dying as a result is NOT a contraindication to give morphine.  Addicted?  The person is going to die, not seek drugs.  They are going to cease to exist.  It is the way of the world.  The verb is “to die”; the noun is “death.”  Use them, not euphemisms.

A sick person in hospice should never, and I repeat never, be denied medication to keep them comfortable.  If hospice workers do not agree, they should work elsewhere. Sadly, this is too often the case in America today.  Ask Barbara Mancini, who was prosecuted for having handed her father morphine, when it wasn’t even clear he was suicidal.  Because that particular hospice was a place where “death is an option in America” occurred, her father suffered hospitalization for four more days before he died.  He didn’t even need to go to the hospital.  Naloxone reverses morphine.  Indeed, I used it in the Navy in the Gulf of Thailand once, and it was the only clear life I ever saved. Ms. Mancini was arrested in the hospice and put through hell for a year and $100,000 by a prosecutor who may be in Congress, now.  The judge who threw the case out of court wrote a scathing 42 page report, if I remember correctly.

Fortunately, the medical profession is beginning to come around more and more to the idea that sometimes we need to allow patients to die.  We need to do whatever necessary to keep people comfortable, even if it means shortening their life.  And in five states, the patient who fulfills certain conditions can choose to shorten his or her final hours, because the end result is the same.

Let’s be clear about semantics, here.  This is not assisted suicide, Dr. Gawande.  Your book was well-written, except for the short shrift and the wrong term you gave to Death With Dignity.  This is an individual who is dying, soon, and does not wish to prolong the process.  This is a individual who is aware what is happening and chooses not to continue.  It is not assisted suicide. The disease is killing the person; they want to live.  But they want to shorten the agony of their final hours.

We can argue as to whether palliative care or hospice can deal with these conditions rather than a Death With Dignity Act.  Maybe they can, but in far too many places in this country, they are not.  That is a fact.  It may be religion, misguided, or financial.  I personally don’t think palliative care can deal with the conscious person with pancreatic cancer, sees the end in sight, and doesn’t want to live it out. I hope I don’t have to find out personally.  In my home state of Oregon and four other states, I don’t have to.

Any hospice that fails to give an elderly woman morphine, because her family members are upset by her breathing, should be closed down.  The lady is beyond knowing, but her family is left with a bitterness that will never heal.  I am both angry and astonished that addiction or “mustn’t give too much morphine to a patient” still exists in the 21st century, when somebody is dying.

It’s nice that Dr. Gawande and others are finally aware at the state of dying in America today.  Welcome aboard the train.  I boarded it 40 years ago in on the third floor of Presbyterian Hospital in Denver. I’ve been riding it ever since.  I’ve known when to quit, and I know how to do it.  I count things, and I think it’s high time we counted the number of people who die at home, the per cent who have living wills, the number whose living wills are violated, the per cent who used hospice, and how long before death they used it, and the number of “Schöner Tod” (beautiful death, a German term).  Everybody dies; on the death certificate there should to be a place for “Living will used,” “hospice,” “hospice at the appropriate time,” and since we are so in love with smiley faces for pain scales, whether the pain scale the last week of life was 1.  Dichotomous question.  Easy.

I wrote about it a decade before you, Dr. Gawande.  Did it in fewer words.  Here’s the link.  It’s in a reputable medical journal.  Welcome aboard.

I’ve been waiting.

BELIEVING IS SEEING

February 9, 2015

My wife read a CT Scan of the heart, done to look for coronary artery calcification, and told the referring physician the patient had breast cancer.

Whoa!  What does that have to do with heart disease?  The answer is nothing, and that is my point: we need radiologists to read films formally, not clinicians, and I say that as a former neurologist who read CT head scans well.  A medical group may own an X-Ray facility and clinicians may read the images.  But every image must have a formal reading by a radiologist, an unbiased individual trained to look at everything on the image, every corner, every part.  There is no law in nature that says a person will have only one disease process.  It is entirely possible for a neurologist to look at an MRI of the spine and miss a large abdominal aortic aneurysm.  We see what we expect to see.  Seeing isn’t believing.  Believing is seeing.  We believe something, and we tend to look for it.  We also are pattern recognizers, often useful, but leads us astray when some see Jesus on a pizza or the “The Face on Mars.”

A CT scan of the Chest has a side view.  This isn’t a mammogram, but it certainly is capable of showing a breast cancer.  In addition to the breast cancer, there was a “ground glass” area in the lung suggesting there might be an early lung cancer, too.  Wow.  A CT scan of the heart is done for coronary disease, and two primary cancers are discovered.  Maybe the cardiologist would have found those, but I doubt it.  I doubt when I read CT scans of the head that I would have found a throat cancer, even though the throat was scanned and on the film.

In my defense, I was once asked by a cardiologist to see a man who had presented with a brief spell of unconsciousness, or syncope. Neurologists are frequently consulted for syncope, and it is usually due to a non-neurological problem.  The man had recently driven 1500 miles (2500 km) from Minnesota to Arizona. I examined him, noting his breathing was faster than normal. His neurological examination was unremarkable. I obtained an arterial blood gas, since we didn’t have pulse oximetry back then, and found pronounced hypoxia.  Thinking a cardiac arrhythmia might cause unconsciousness (strokes seldom do), thinking a pulmonary embolus could cause both an arrhythmia and hypoxia, I obtained a lung scan, since that was once the “gold standard” test. The man indeed had pulmonary emboli, likely because of venous clots in the legs occurring during prolonged sitting on his long drive.

It seems trite to talk about the “good old days,” when they were not always so good.  We didn’t have the technology we have today.  On the other hand, I think our physical diagnosis—history and physical exam—was a lot better than today.  We didn’t have scribes writing down findings and ordering a plethora of tests, many of which require a lot of radiation.  More than once, my wife has told me of head CT scans or MRIs with a specific lesion.  When I asked her what the history was, she usually answered:  “It was part of a complete body work up.”

That approach makes modern medicine foreign to me.  I ordered tests I thought I needed, and if I weren’t clear in what order I should order them, I called the radiologist.  I always wrote much information about the patient on the requesting slip, back when we used paper and still knew how to write, because a radiologist could give me a better reading when they knew the area of the brain or spine in which I was interested.  When I could, and I usually made sure I could, I would look at the films with the radiologist, when we still had films, so I could see for myself and learn more about reading images.  It made the radiologist better and feel more useful; I believe it made me a better neurologist.

So, when the MRI of my neck, done because of a concern about a pinched nerve, was unchanged from 9 years earlier, that was good news. I was chagrined, however, when the radiologist told me that I had a two thyroid nodules that were missed by even the radiologist back then.  It never occurred to me look for thyroid disease on my neck MRI.  It is sort of like people’s being surprised when I tell them the Moon is visible in broad daylight.  “It is?” they say.

“It’s there, isn’t it?”  I reply.  The thyroid nodules were definitely there.  Once I looked, there they were, quite obvious, like the first quarter Moon in the southeastern sky in the afternoon.  Try finding the Moon in daylight, if you haven’t ever noticed it.  The Moon is above the horizon half the time, and other than 2 days on either side of new, it is visible, day or night. You will discover a whole new world—literally, and wonder why you never noticed it before.  That’s the problem.  We notice only what we are willing to notice.  If we learn to notice many things, it opens a door to a new world.

Sometimes, we notice a thyroid nodule.  Sometimes, we don’t.  I was lucky; the nodule was benign.  Had it not been, my thyroid cancer’s discovery would have been much later than it should have been.

Sometimes, life itself lasts longer when people notice things.

STREET SMARTS

January 25, 2015

Back in ’86, I had just arrived at the canoe outfitters east of Ely, Minnesota, and used a pay phone to call my wife, before soloing in to the Boundary Waters for a week.  One of our cats had just died, and we were both grieving.  I asked her about “Tribble,” a small grayish- white stray found in a fast food parking lot, whom we had just taken in.  My wife’s voice changed immediately when she started talking about the kitten who would become pure white when clean and grace our lives for a decade.

One never can replace an animal, but one can give a new one a home, helping the grieving process immensely.  I don’t use the relative pronoun “which” with animals, only “who” or “whom.”

*********

I got the text from my wife while I was running north from Knickerbocker Bridge on my way home.  “We just put Patience down.  It was time.”  When I got home and called Arizona, the other end of the line was full of silence punctuated with tears.  What could I do?  Nothing but listen.  For an animal person to lose an animal is tragic.  We are animal people.

Patience was a horse born into my wife’s arms 17 years earlier one night.  She was a demanding creature, and while I don’t normally visit my wife’s horses, I once had to do the feeding, and Patience was not.  She was queen of the herd and had to eat first.  She was not big, 15 hands 1, maybe 2 on a good day with windage, but she more than made up for her size with her personality.

Sadly, as the years passed, Patience developed leg problems, which ultimately led to her foundering, a painful condition where there was a real possibility the Coffin bone will come through the hoof. While there was initial hope that the hoof would grow back, a later check revealed that she would not survive without a great deal of pain and no guarantee she would ever walk normally again.  She was euthanized before my wife’s eyes.  I wasn’t around to be there; her best friend, whom I will call Babs, was, and the veterinarian suggested the other horses in the herd be brought up to see the corpse.  Several sniffed at her, then started eating her hay.  Mind you, I didn’t hear the last part, or the next part, for several days; it was too painful for my wife to discuss.

Horses are something we don’t talk about much.  My wife is a different individual at the barn.  I seldom ask, but the few times my wife opens up, she vocalizes a torrent of equine-related words:  “When you euthanize a horse, they are standing up.  Patience fell, as she lost consciousness, and the bang, when she hit the ground, startled the rest of the horses.  They knew this was not an ordinary fall. They called out in a most unusual way.”

I never knew this stuff occurred.

My wife came back to Oregon for 2 weeks, still grieving and stressed out about having lost two horses in the past 10 months.  Babs’ daughter, who lived in another state, happened to see an advertisement in a journal for a horse.  “She looks really nice,” was relayed to her mother.  “Then I saw she was for sale in the Phoenix area.”

Babs decided to drive up to Phoenix and check out the horse on a weekend my wife was working there.  It would take me 2000 words to describe Babs properly.  She is a generation younger than I but probably a generation ahead me in street smarts, and I’m no dummy.  The thought of driving 3 1/2 hours to Phoenix to check out a horse was entirely consistent with her character.  She and her husband once picked up several horses in Colorado, a 13 hour drive one way.  Or was it 15?  Their property is full of dogs, cats, horses, ducks, chickens, and once “Miss Piggy,” a pot-bellied pig.  Babs knows everything that is going on in the county, on 2 or 4 legs, on the opposite side of the political fence from me, except where stupidity is involved.  Neither of us suffers fools gladly, and we’ve helped each other with serious stuff that I wouldn’t do with many others.

Babs and my wife planned to meet for dinner in Phoenix that weekend and see the horse, who was called Ally.  Both agreed that Ally looked good, the price reasonable, and they decided to get her vetted. I got a picture texted to me.  Sure the horse looked fine, but what do I know?   My wife was not optimistic, but it got her mind on something else, and that was good.  But, on the following day, the vet called with bad news:  the agent was a deadbeat, we might not be getting a fair deal, so Babs decided not to go ahead with the vetting.

Funny thing was, the vet also said, “She looks like a nice horse.”  That made 4 who had said that, 5 counting me, but I don’t count.

Nonplussed, Babs texted my wife and said she still wanted to move ahead.  Turns out Babs already had a grain bucket with “ALLY” written on it.  The vetting was moved to Friday, and I was about as curious as my wife what would happen, although I thought I knew.  A good vetting may ferret out that many give a horse Ace (Promazine) or Bute (butazolidine, an anti-inflammatory) before a sale, so if the horse is arthritic, may not appear lame to a buyer.

I also learned some mares are given progesterone because when they are “in season,” they can be unmanageable.  Progesterone prevents ovulation.  Three months after the sale, the progesterone is gone, the horse goes into season, and there is an issue.  We didn’t need that.

With all of those caveats, Babs wanted this one.  I didn’t mention that Babs negotiates like the main character on Pawn Stars.  I don’t know what she offered, but in the end we got the horse for a whole lot less.  She and my wife were texting constantly.  For Babs’ SMSs, my wife has a train ringtone on her phone; I kept expecting to see a Union Pacific locomotive in the driveway.  She seemed a lot less depressed, too.

Ally wasn’t easy to get into a trailer for the trip out of Phoenix. I believe Babs used the word “turd” to describe her. That would be about right.  Babs has a doctorate in Street Smarts; her ability to find the right word is uncanny.

“We’ll fix the trailer issue quickly,” was the next text.  Yeah.  No doubt.  Maybe in a day.  If that.

My wife is a lot happier than I’ve seen her in awhile. Think Babs is, too.  When I heard there was a grain bucket with “Ally” on it, I knew what was going to happen.

I’d never dream of telling my wife that, however. Street Smarts.

CALCULATED RISK

January 19, 2015

“Well,” I said, looking at the student’s math problem, “everything is fine until here:  you have (-14/23) + (15/23), which is correct, but you wrote they equaled 18/23.”

“What should it be?”

The student paused.  I continued,  “What is minus 14 and plus 15?”

She took out her calculator.

“No,” I said.  “No calculator.  What is minus 14 plus 15?”

She thought for a few seconds. “One”.

“Exactly.”

“I must have pushed the wrong button on the calculator.”

I tried not to cringe.  “You don’t need a calculator to add minus 14 and plus 15.  By using a calculator, you run the risk of pushing the wrong button and believing what comes out.  Use your head.  You knew what it was.”  The woman nodded.

We tutors sat alongside a wall at desks, and students, who sat at one of many tables, working on math problems, would come to any of us if they wanted help.  I spend four hours, sometimes more, two days a week as a volunteer, and I am usually busy the whole time.  A fellow tutor about my age commented how we once had main-frame computers (the adjective has now almost disappeared from the language) that took up a whole room, required air conditioning, and needed punch cards to do simple calculations.  I can remember learning BASIC, written by John Kemeny, mathematician, teacher, entrepreneur and president of Dartmouth College for 11 years, including the year I graduated.  Kemeny was a genius.

In 1969, Wang calculators appeared in a small room in the chemistry department, where I was a major.  These were slightly smaller than a laptop keyboard, and we could then do exponentials and natural logs.  We used to use log tables to do calculations. Our generation knew the word “anti-log” and the term “9.xxx-10”. If you know what I mean, you are at least 55.  We thought these new calculators were incredible.  We could put away our slide rules.  Imagine, cube roots by pushing buttons! We played with [ln (0)], to see how the calculator handled undefined numbers.  It was fun.

Now my TI-83, a rather old calculator, can graph any polynomial I want in any size graphing window I want.  It can give me the values of derivatives, intercepts, z-values for proportions, t-tests, Chi Square values, raise numbers to the 100th power or more, which makes interest calculations easy, store numbers, do linear, quadratic, cubic, and exponential regression, has a built in z- and t-table, does binomial calculations, take n th roots of things, and fits in my back pocket.

What it cannot do IS TELL ME WHAT TEST I SHOULD USE.   Nor for that matter, can it square any number with 25  digits, all of which are 9, as fast as I.  I think I can multiply any pair of two digit numbers as fast.  Squaring three digit numbers ending in 5, I can also come close to beating it.  But graphing y= [sin x/(x-2)]^2]?  No way I can come close.  I can do logs to the base 10 of 2,3,4,5,6,8,9, and 10 to 5 decimal places faster, but I can’t do the log of 7 or larger primes. I can’t do them to six or seven places.  Nor can I do trig functions other than the simple 30, 45, 60, 90 and multiples.  But I can estimate them quite closely, which surprises people, when I say the tangent of 35 degrees is about 0.7.  The tangent of 30 is √3/3=0.5773, and the tangent of 45 is 1, so I just interpolate.  Many times, that is all I need.  I am metric fluent, but I can’t use polar coordinates well.  The TI-83 does that and shifts to radians with a couple of key strokes.

These calculators are great.  BUT THEY CAN’T THINK.  They take your thoughts and input and give the result.  They don’t say whether you asked the proper question.  They don’t tell you that a quadratic function might fit the data better than a linear function, They will tell that you inputted an incorrect formula but not a wrong number.

Nor will the calculators say if you violated the assumptions with linear regression, something that many people who argue against global climate change, for example, fail to recognize.  One cannot simply make a scatterplot, draw a line through the points, or even have a calculator do it, and conclude nothing has changed in the last decade.  A calculator can minimize the sum of the squared vertical distances of the points from the line, showing the best “fit”.  It can do it faster than I, although it can’t prove why the formula works, and I can.  A calculator can show whether the line is going up or down, even how much, and if one asks for more, the p-value for the line, the probability the occurrence is different from a fixed number’s being a chance occurrence. The calculator, however, cannot cannot tell you whether the distance of each of the points from the line follows a normal distribution with mean 0 and the same variance, without some work and judgment from the user.  Nor does it tell one whether a point should be an outlier.  That also requires judgment.

Calculators have to be used for the right things, just like computers, and one needs to have an idea when the answer makes no sense.  If I Google “East Pacific Ridge,” wondering why the Jet Stream Wave #3  has stayed stuck for so long, which is devastating the American West, I might read something that says only warm moisture from south is getting through, because of the radiation in the water at higher latitudes from the 2011 tsunami can’t, which is nonsense, akin to pushing the wrong button.  We push wrong buttons sometimes, or we forget to erase something in the calculator.  We look at an answer and should realize it makes no sense.  That ability has been greatly diminished, and in some places has disappeared, along with my slide rule.  I am not a whiz with a calculator.  But I have the ability to look at an answer, a graph, say about what things ought to be, and whether the answer makes sense.  I agree that Common Core is teaching estimation, but there are multiple ways to estimate, and children need to be taught multiple ways to do math, because they learn differently.  I estimate differently from the way Common Core does.  I learn differently.  Indeed, discovering how an individual learns is one of the most important things education should do.

A 10% increase in the likelihood of a rare disease is not 10% likelihood you will get it.

Decrease in the rate of growth does not mean the total is declining.  It is not.

Four different outcomes do not mean they all have equal probability.  They usually don’t.

There’s a place for the mean and another place for the median.  A person who uses them interchangeably to describe a set of data is either lying or doesn’t know the difference.

Finally, (-14/23) + (15/23) can’t possibly be larger than (15/23).

CONVENIENCE

January 17, 2015

Two days ago, when I got into the car, it wouldn’t start.  It was dead.  No click, nothing.  I had two choices:  one, get the car jumped, drive to an auto parts store, remove the battery, buy a similar one, install it there, then drive home.  I could have paid less. The issue would have been only if I happened to stall on the way to the auto parts store, or if the problem were not the battery but a faulty starter, which sometimes will still allow the car to be jumped.

Instead, I called AAA, using my membership, under $100 annually, and in 20 minutes someone came over, tested the battery, said that indeed I had a battery problem, and sold me another battery for $116, including installation.

During past battery self-installations, I have lost screws and once dropped two wrenches into the heat shield of the car, where eventually they fell out as I turned a corner one day. I may have paid more than I could have, but having AAA come over and take care of my problem in 45 minutes was convenient.  It was worth it.  I didn’t get upset, I didn’t have to look at batteries, I got what I needed, and I got it installed.  If I happened to love cars, I would have enjoyed the work.  I don’t enjoy putting in batteries.  How much is the convenience worth?  I don’t know.  But it is worth something, and the older I get , the more worth I ascribe to convenience.

Convenience matters.  We left money on the table when we sold our house.  It was worth it. Not having to worry about the house when we left Tucson was worth a lot.  How much?  I don’t know.  I don’t really care.  It was one less major stress.

It costs me to have somebody clean the gutters.  I can do it myself.  I also can fall off the ladder.  Don’t laugh.  My wife, a radiologist, has told me countless stories of X-Rays she has read of people who fell off ladders.  The stories are gruesome—severe head injuries, dislocated ankles, hemothorax, or blood in the chest.  My father fell off a ladder when he was 77; his shoulder was never again the same.

Convenience stores are called that for a reason.  One pays for it.  If one needs a loaf of bread at 2 a.m., one pays a little more and gets it.  All insurance is a convenience.  I can put away money in case my house burns down.  Or, I can pay something and not have to worry whether I am putting away enough.

Urgent Care is a convenience, too.  One pays more for care there than with one’s personal physician, but if I have a bad cough on the weekend, and am concerned about pneumonia, I can get the answer then, not wait until I can be seen by my physician.  Yes, it costs more.  Being hospitalized for pneumonia that might have been prevented is costly, too.

With all of this in mind, when should one take Social Security, when they are 62, 66 (or the current “normal” age), or 70?

Virtually every financial advisor, including Suze Orman (who has changed her mind on the issue) says one should delay as long as possible.  The longer one delays, the more one gets, increasing approximately 8% per year.

A New York Times columnist says he has gotten many spreadsheets from people saying why taking Social Security earlier is better.  He doesn’t agree with them.  He’s right, from a purely financial, logical standpoint.  If one looks out to age 77 or beyond, taking Social Security later turns out to be significantly better, assuming one can predict inflation and one’s longevity.  If inflation stays low, and one lives long, without a doubt, starting Social Security later will be a better choice, if it is a matter of money only.

The issue with finance, however, and indeed with investors, is that we are neither logical nor rational when it comes to money, and that is not necessarily bad.  I haven’t heard “convenience” in any discussion about Social Security, since like many things in the world that have value (love, friendship, caring, kindness; pollution, degraded views, ugliness) convenience is often construed not to have value.  It does have value, but the individual has to decide how much.

So, what was convenient about collecting Social Security at 62?  At the time, I was retired and appreciated receiving money monthly.  It was a psychological boost, pure and simple.  I like to think that I enjoyed the money more at 62 than I will at 72 and 82, assuming I live that long.  Indeed, I’ve received money for the last 50 months, rather than not getting any by waiting.  Does that matter?  It depends upon one’s circumstances, inflation, and taxes.  How important is the psychological factor? I don’t know, but I think it is significant.  Four years into this, I have no regrets.

If it takes me until I am 78 until I start to lose money, or even earlier, I’m not going to be upset.  For 16 years, even 10 or 12, I was ahead of those who waited.  After that, they will have received more money from Social Security than I. I hope they enjoy it; I hope they use it well and are happy.

When should one take Social Security?  If one purely wants to maximize income, wait until age 70.  One gets about 80% more per month than at 62, but one also needs several years to make up the initial difference.  For many others, wait until 67.  The table shows it clearly.  There is no right or wrong answer, if one factors in convenience and psychology to the financial picture.  I believe that convenience matters.  If having the money now, even if less, to deal with the present is important, then taking Social Security early is the best move.  If getting more money later is more important, taking it later is the better strategy.

BORN 1943-54:                Age 62=75;     Age 66=100;   Age 70=132

BORN 1957                        Age 62=72.5;  Age 66=96.7;  Age 70=128

BORN 1960 OR AFTER        Age 62=70;    Age 66=93.3;  Age 70=124

I don’t underestimate the worth of those things that either cannot be or are not measurable.  If we factored our Middle Eastern policy into the cost of gasoline, we would now drive cars getting 150 miles per gallon, if they even used gas.  If we factored into the cost of food pesticides, transport, waste, and environmental destruction, we would be eating differently.  Economics often deals with things that can be clearly measured, using nice mathematical formulae, too often assuming those variables, and only those variables, are all that matter.  They don’t. We are emotional beings who think we are rational.

Life is not as simple as we would like it to be.

CROTCHETY MAN BITES BACK

January 11, 2015

“Do you want to be called Mike or Michael?” said the young woman, a third my age, cheerfully, as she led me to the dentist’s chair.  I mumbled, “It doesn’t matter” and sat down.

I wasn’t looking forward to the visit, since it was my first dental exam in a new city.  Being called by my first name by strangers much younger than I, without my permission, wasn’t a good start, either.  I find it a little rude.  I realize my feelings may not be the norm.  Many might say, “Get a life” or “suck it up,” which is why I didn’t tell the woman anything.  I was brought up to be polite to elders, and sometimes being quiet is the best behavior.  I was also in the military, quickly learning to call superiors “Sir”.  Few of the young have had that experience.

I practiced medicine for 20 years, calling very few patients by their first name.  I just didn’t do it.  I didn’t mind when nurses called me by my first name, or if they called me, “Dr. Mike,” which I found endearing, because it simultaneously showed both respect and informality.  I used “Sir” to answer lawyers, and it devastated their ability to get my goat.  It’s difficult to argue with somebody who keeps saying “Sir.”

One needs to develop a sense for whom informality is appropriate. My next door neighbor is 21 years my senior, but I use her first name.  The chief of neurology, when I was a resident, is about her age, but I have never once called him by his first name, nor would I, should I ever see him again.  I don’t think he would mind; I would.

Online, first name basis is the norm, and many take advantage of it, saying things they might not say face to face to an older adult.  Or maybe they would, since today, young is good and old is….well, not so good.  I’m crotchety, I guess, but I think since English doesn’t use the informal second person pronoun, we need to show respect in other ways.

I received a survey after the initial evaluation, since virtually everybody in the service industry surveys these days.  It was not anonymous, making me more reluctant to respond.  Surveys I like have three questions:  Did you like the care?  (Yes/No)  Would you recommend us to a friend?  (Yes/No).  What can we do to be better? These are fundamental questions, easy to answer, and offer a chance to receive good suggestions.  They are neither a census nor randomly generated, so one must still be cautious in interpreting the numbers.

I was going to blow the whole thing off, but the way I had been addressed still grated on me, so I decided to express my thoughts—politely—on the issue.  It is never wrong to call adults “Mr.”, “Ms.”, “Mrs.” or “Dr.”.  It is appreciated, and if the individual feels you are too formal, they will tell you to use their first name.  Unfortunately, the survey required an answer to every question in order to be submitted.  So, I had to give a number of stars to everybody, fill out another box for comments, and…..whether I was on Facebook.  You see, they wanted to post my comments anonymously or with my name on Facebook.  

I must be getting stodgy, because the idea of a dentist, or any physician, using Facebook for posting patient evaluations seems weird, especially given privacy regulations.  When I received the survey, I had only digital X-Rays, gum probing, and an estimate of what I needed, a screen view of every one of my 24 teeth and the itemized bill, visible without leaving the chair.  I was glad to be sitting when I saw the bill, in four figures, double what I have paid for dental work in the last decade, including a root canal.

Because I hadn’t filled out every box, I still had the choice to quit or finish.  I suspected that all the stars I had to put for each individual involved would be averaged, and that bothers me.  I’m a crotchety old guy.  Stars are ordinal data: 1 star and 5 stars should not be averaged to get 3 stars, unless the stars stand for interval data, like temperature, money, or speed.  Love and caring are not interval.  I then added something I had forgotten.  Prior to the appointment, I had received 3 e-mails, a call (6 days earlier), which I had to acknowledge by calling back, and an SMS the day of the appointment.  That is over the line.  In my day, even calling patients to remind them wasn’t done.  I now think that is a good idea:  One call is reasonable, without requiring a call back to acknowledge.  A statement that one may be billed for a no show is entirely appropriate.  Professionals shouldn’t have their time wasted.  Really, an SMS?

Why didn’t I have dental insurance?  Good question.  Three-quarters of people over 65 do not have it.  Twenty-five per cent have lost all their teeth, 40% if poor.  About 60% have significant periodontal disease.  My dental costs per year for the last decade were minor, and I had been doing well.  I had no reason to think matters were suddenly going to change.  Bad decision.  Dental insurance has pre-existing exclusions, and now that I have been examined, I have them.  What I find interesting and disturbing is that AARP, which bombarded me about medical plans, was more silent about dental.  There is a one year waiting period for a crown and periodontal disease, and coverage is about 50% of the cost.  That’s crummy.

More than half of Americans have some sort of dental disease.  For the elderly, it is yet another cost to have insurance, although chronic periodontal disease can cause systemic problems, which increase medical costs.  Since the Affordable Health Care Act is under fire, don’t count on dental coverage in the near future. Many elderly can’t afford four figure costs for dental care, so they do without, dealing with the worst thing first, hoping something else bad doesn’t happen.  This is how many Americans deal with medical issues.  This is how many Americans deal with financial issues.

If you are young and in the service industry, call older people “Mr.” “Ms.” “Sir” or “Ma’am” as a default.  They may not like the bill, but at least they may be addressed appropriately.

Twenty-two days before my next appointment, and I just got an SMS and an e-mail, reminding me.  I’m waiting for Viber and WhatsApp to sound off.  Fortunately, I don’t have Twitter.

FIDUCIARY RESPONSIBILITY

January 4, 2015

Years ago, my wife was on the Blue Cross Advisory Committee advising them whether certain procedures qualified for coverage and payment.  Reduction mammoplasty was discussed one night, where excessive breast tissue, a significant problem for some women, is removed.  A lot of men don’t understand the issue, but large breasts require a woman’s back and neck to compensate for the torque, causing pain. Skin rubbing against skin causes redness and infection.  There are women who benefit greatly from this surgery, and my wife argued that it ought to be covered by insurance.

Others commented that some physicians would use this coverage as a way to do plastic surgery on women who wanted their breasts reshaped, not true reduction mammoplasty.  This is “gaming the system” or “cheating.”  To my wife, the issue was whether Blue Cross would deny the procedure to women who were suffering because of cheaters, or cover it anyway.  Nearly all of us have suffered because of a few bad apples ruining it for everybody, with the flagrant exception of guns, where virtually no restrictions apply.

Reduction mammoplasty was paid for.  It was one of my wife’s quiet triumphs; she doesn’t brag about them.

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

We should have walked out of the mall on New Years’ Eve without going by the Sprint counter.  Between that and the endless cold I’ve had with laryngitis, it was another crappy holiday season.

We have two carriers for two phones.  AT&T works well in cities, but it doesn’t work in most wild places.  I accept that.  My wife uses Sprint; her phone works in Arizona but not in the house in Eugene, a reasonable-sized city.  If her phone rings, she makes a beeline to the bathroom, where the reception is best, before the call drops.  She has been to the Sprint counter three times, and got a quote from another carrier that she liked, but she needed the phone “unlocked”.  That will be legal in February, finally, but may be difficult for Sprint phones.

At the counter, we went through the same discussion about her phone with a different person.  Time passed, and we should have just told him we had already discussed this.  Neither my voice nor my mood was improving.  We heard about how bad other companies were; well, Sprint wasn’t working for us.  Finally, we were offered a booster device for free; prior to this, we were told we had to buy it.  We had heard at a computer store if one got insistent with Sprint, one could get the device for free.  I find that dishonest.

We finally saw three employees huddling in a corner near the kiosk, I guess trying to discuss what to do with this old couple who clearly weren’t happy.   Later, one told me that 3 bars was all he got, and the number of bars doesn’t matter.  Actually, it does, and I drew a exponential graph, showing that 1-2 bars is pretty much the same, 3 is a little more, and 4 or 5 are significant.  I may not know much about the various CDMA and GSM technologies, what bands the carriers run on, and the various models of iPhones.  I do know something about dropped calls and people who can’t hear me.

I finally told my wife, “15 more minutes,” because we weren’t making progress, wasting yet more time in my life, in which I have wasted enough.  The second guy was still on the phone with customer support, “because your call is important to us.”  In any case, at this point, a slightly older man, number three, probably the manager, started to talk to us.  He should have been called right away, when it was noted we had been here before, and we had a difficult problem.  That is what managers get called and paid for.

He asked a good question:  “What would make you happy?”  My wife said that a working phone in the house would help.  He then started going through the same fixes we had heard about three times—or was it four?— to the point where I just walked away.  When I returned, he was still going, time was passing, and when he said, “usually” referring to getting a free booster, I walked away for good.

The booster is so simple, we were told it just had to be “plugged in”.  Well, not exactly.  There was a 5+ minute video on YouTube which involved a lot of unplugging and plugging, followed by a cord to run a GPS to a closed window.  That wasn’t going to work for us.

I don’t like the telecommunications industry, and it goes back to the ATT deregulation of 1984.  It ruined phone service.  For years after, I was shouting into most phones, often claiming we had a third world telephone service, well before cell phones.  Don’t laugh.  I’ve texted home from central Kenya better than I could text from my driveway when I lived in Tucson.  The companies now have us hostage to our phones or vice versa.  Take your pick.  Where is fiduciary responsibility in America today?

When I practiced medicine, my job was my patient’s welfare, concomitantly recognizing that resource use affected all patients, and I had to be a steward of society’s resources, too.  I got up in the middle of the night, was yelled at, spat upon, threatened, in order to treat patients, many of whom didn’t pay me ($30,000 worth of unpaid bills every year), could sue me if I were wrong, but had the right to the best care I could give them.  I didn’t do unnecessary tests to pad my wallet.  I did what I thought I needed, charged fair prices, often discounted them if the condition were simple, like a spontaneous facial paralysis (Bell’s Palsy).  This is fiduciary responsibility.  The patient’s needs come first.

I expect my financial advisor to act in MY best interest, not his.  I dropped one because he recommended only his company’s products.  Health insurance companies in my view have a fiduciary responsibility to cover what should be covered and not covering what shouldn’t be. I remember how upset many were when bone marrow transplants for breast cancer were not covered.  They were not proven to work.  Not paying for it is not the same as saying the person can’t have it.  The procedure was eventually abandoned.  Reduction mammoplasties are covered.

I’m a naive, old, retired physician.  I had a fiduciary responsibility for my patients.  It took so much out of me that I eventually quit practice.  Companies have fiduciary responsibility to stockholders and to their customers.  It’s a balance:  do-gooders can go out of business for not collecting money.  Others run highly profitable margins at the expense of their customers.  The rules in medicine were different.  We took care of people first.

I did not have a sign in my office saying, “Payment is expected at the time of service.”  Silly me.

HOW TO KEEP….AND LOSE VOLUNTEERS

January 2, 2015

I was thrilled when I discovered the solution:  the student had forgotten to cube both numerator and denominator constants when she inverted 1/[(sec x)^2] to (cos x^2).  Two other tutors hadn’t seen it, and I haven’t done trig calculus in years.

When I first looked online at Lane Community College to become a volunteer math tutor, it appeared that I needed to take an 18 hour course in how to teach.  I was a bit miffed; I have taught math for years.  When I arrived in Eugene, I went to the downtown office and was given a number to call, but that didn’t help, either.  I waited, since it was summer.

In September, I called the college and this time given the e-mail address of a person whom I should contact.  To my surprise, she e-mailed me right back and said I could come over to talk at the end of September.  I did that, met her, and learned how the system worked.  She asked me when I wanted to work.  I set up some times and went to work.

The system at Lane is good, interesting, and my hours are flexible.  I often go when I have free time, for there is always a need.  The tutors have desks along the wall with a computer to look up things.  Students study in the room; if they need help, they go to one of the tutors.  If all are busy, the student waits in one of the chairs along the wall until somebody is available.  I get every math issue I can imagine, from men and women, young and beautiful; old, with a lot of miles on them; tattooed, body piercing and hair color I can’t believe.  One, 76, was recently released from prison after four years.  All are there to learn; all deserve help and respect.  Some come to me if I’m the only one free, preferring other tutors.  I don’t care. I help all comers, and if I don’t know something, I look it up quickly online.  I’m good, not perfect, but when I can explain basic algebra to somebody, lining up equal signs, balancing equations, what can and can’t be cancelled, showing short cuts, trying multiple approaches, completing squares, they are appreciative.

I’ve handled math from subtracting fractions to integral calculus.  The latter has been difficult, but I am amazed at what I have pulled out of the air.  I am the go-to person for statistics, since I have a master’s in it.  The other day, I helped a guy use a compass to make a 30-60-90 triangle.  One of the tutors asked me if I knew how.  I didn’t, but quickly figured it out.  Tutors help each other.

Every day, when I leave, I am thanked for doing what I love.  Amazing.  It works; one day I was told twice, “I saved the day” by showing up. The week before finals, I went four days in a row.  I have worked solidly for five hours.  I bring material to read and it stays unread, for I am busy. I like what I do, I am helping people, I am appreciated, I am making a difference.  I look forward to tutor day at Lane.

I also volunteer at a reading program for first and second graders.  Reading to children is important.  They need to hear the sound of words, the rhythm of the language, and discuss the book.  They begin to learn pronunciation.  They need to discover that books can take them places they can’t even imagine, and allow them to see the world without leaving a house.  I taught myself to read when I was 3.  I read the newspaper, sitting on my father’s lap.

I signed up at an elementary school that needed volunteers and was within walking distance of my house.  I was a little leery, because several years ago, I tried to teach a 35 year-old how to read, and it was extraordinarily difficult.

The school doesn’t fully buy-in to the program.  I know that as soon as I walk in the door.  I sign in at the front office and get my name tag.  Nobody greets me.  The coordinator left for another job, and nobody told me or the other readers that was going to happen.  A volunteer took it over, but she is a volunteer, not a school employee.  We start at 11, a bad time, because we may only read during lunch and recess, not at all good for students, but that is what the school wants.

I have to go to 3 rooms, get the children, who should be ready immediately, but aren’t.  Then we walk down the hall to the cafeteria, and when we should be beginning to read, we are waiting for the dietary personnel to open up the serving line, which they always do, a few minutes late.  The children go slowly through the line, then get silverware, napkins and salad dressing, FINALLY walking outdoors 50 yards, with their trays, eventually arriving at the reading room.

By the time we choose a book to read, we are 10 minutes or more late. I try to read to a child who is hungry….or not….eating, or not…., looking out the window at recess, and paying attention…. or not.  When we finish, they go to recess, we get the next group and repeat the process.  What was supposed to be an hour is an hour and a half.  Reading to kids while they should be at recess and are eating is sub-optimal, messy, with dropped food, and because the child is eating, he cannot fully concentrate.

I leave, glad I’m done, and walk home.  I don’t think I have accomplished anything, except setting a new record for the duration of a cold.  I was originally told my commitment was half a year; now I am told it is a year. When a couple suddenly left for a month because of the birth of a grandchild, I was told to read to their students, not mine, which I thought not fair to either me or my charges.

It’s a bad fit for me.  I believe in reading to children.  I believe adults should do it, and the parents should, if there are parents.  Having children brings the responsibility to read to them.  I was not put in front of a TV when I was a child. I was read to. I had to write book reports, too.  I learned to look up every word I didn’t know, to improve my vocabulary.  That’s what students need to do. I’m concerned whether computer screen reading is as effective; I know how easy it is to be interrupted on line.

I think we need those with means and time to volunteer in schools before or after classes, nights and weekends. The schools need to welcome volunteers with good systems in place to use them effectively.  Parents and the community must be involved.  This should be easy, but in my experience in high schools, it is not happening.  Why? Teaching to tests isn’t new. I grew up in the Sputnik era, however, when the world changed, and America got a dash of cold water in the face.

I tutor math where I am wanted and make the subject come alive.  For now, I read to kids who are hungry and distracted at a place where it doesn’t seem to matter.  It should.

A lot.

 

 

GOBS OF MONEY

December 29, 2014

In 2002, I discovered  to my chagrin that I wasn’t going to get served a meal on a four hour flight.  That was an annoyance, but it was only a minor harbinger of the future.

A recent spate of articles in The New Yorker has alluded to the difficulties the average traveler has flying.  Those who fly frequently pay for certain conveniences: $85 for TSA pre-check, faster and friendlier, and not in stocking feet, $25 per bag check-in, so I go carry-on with a day pack crammed with everything I may need, and early boarding (Zone 2), which is a $89 annual fee on a credit card for which I can get a free flight in maybe a decade.  Zone 2 allows me to put my carry on in the overhead early, before it is full.  There are $6 “snacks” and $6 Internet, too.  I now bring a lunch.

First Class round trip from LAX to Australia is $13,000, and people pay it, either with their money, or corporate money, which is all of our money, since “corporate” got it by selling somebody something, and probably got a tax break on it, too.  Fly from Seattle to Amsterdam round-trip costs about $1200;  another $7000, you go first class.  I paid $7000 to take a course on quality in medicine that changed my life, although I never got rich from it.  I’m retired, should survive, but I can’t comprehend paying $7000 to sit in a different seat.  My wife says, “If you have gobs of money, why not?”  She’s right.  Economy seats have shrunk; the largest seats are about the same size as the smaller ones two decades ago. Why sit in the back if you can afford to sleep lying down up front, if you got the dough and you’re old?  It just seems ostentatious to me.  I know several not for profits who would be thrilled to have that $7000.  It would be life changing to seven students at a community college I support, if each of them got $1000.  I know.  I’ve read their letters.

Jet Blue finally bit the bullet, the last airline not to charge for what were once called “frills,” giving the airlines a huge profit.  What is not surprising is that fares have not recently declined, despite the fact that the single biggest cost—fuel—has become far cheaper.  But as soon as there is a rise in the price of crude, it is immediately translated into increased prices.  It was like the price of silver and film years ago.  When silver became expensive, so did film, immediately.  When silver became cheaper, well…….

The only thing that still hasn’t changed is that we economy folks get to the same place at the same time.  Now, we don’t get inside that place at the same time, but the arrival is still equal.

Gobs of money.  That’s the term.  There are people with gobs of money.  Not $3650, which puts one in the richest half of humanity, but gobs.  The richest one percent in the US own more wealth than the bottom 90%.  The top 1% make $519K, the top 1.5% make $250K.  The richest 1% pay 24% of federal income taxes, and they state that isn’t fair.  I counter with Willie Sutton’s Law:  When asked why he robbed banks, Sutton replied, “That’s where the money is.”

Wealth management pays well.  I was turned down for a trust company because my net worth hadn’t reached their minimum.  They mentioned (and they had no business saying it) that one of their clients had a net worth of $350 million. That is gobs of money.  It is incomprehensible, I don’t know who makes that kind of money, but to me that screams “charges too much,” “ought to be giving a lot to support poorer people, public education, scholarships” “ought to be taxed on it,” “drugs?” and other socialistic statements.  Really, $350 million?

High end stores survive recessions well, because there are always those with gobs of money.  Five thousand of these folks got more than $1 million in bonuses in 2009, ($20 billion total were paid in bonuses) after the economic disaster they created starting in 2005 came home to roost.  What has changed is that many have become more ostentatious with their houses, cars, and the right schools.  I’m not talking about a good college, I’m referring to the right kindergarten.   When I practiced neurology, we had to make a rule that only four times a year could somebody take their salary early, because some of those earning $400,000 a year were asking for it because of “needs”.  The day we discussed that topic, I thought I was on Mars.

“I earned my income,” I could say.  “I studied hard through high school, college, medical school, and residency.  I did it myself.”  Well, yes and no.  I lived in a country that gave me free public education, good teachers, cheap medical care, infrastructure, subsidized college education, both by alumni and by the government, paid for defense (and I had to serve), and had a progressive tax code.  That’s all gone now.  Most of these people are white, male, and have connections.  I had two out of three.  The rest often work just as hard and aren’t as lucky.  The people on the bench spend just as much time working as the starters.

There is something wrong with a country where employees need food stamps and health insurance, while their employers have $125 billion ($125,000,000,000) net worth.  There is something wrong when 20% of the homeless are veterans.  There is something wrong when people traveling with children can’t board before first class passengers, where an airline is going to proffer “economy minus” seating (stay tuned), where Germany offers tuition-free education, while our students are saddled with huge loans, and the outgoing (read: fired) president of the University of Oregon got nearly a $1 million severance package for his subpar leadership.  Personally, I would have been embarrassed to take it, slinking away quietly.

There is something wrong in a country where quarterly earnings matter more than long term thinking, where hitting financial targets are more important than public health targets: reduction of teen pregnancy, domestic violence, gun violence, obesity, smoking, and numbers of uninsured, to name a few.  There is something wrong in a country where the CEO/worker pay ratio was 20 when I was in college, 60 in 1990, now well over 200.

There is something wrong with a country where we have $1.1 trillion in student loan debt, not dischargeable through bankruptcy, has 11% default, changes what jobs people get, and is a tremendous burden.  A 0.125% tax on all stock trades ($1.25 per $1000) would generate enough money by 2026 to pay off current student loan debt.  That’s the America I’d like to see.

There is something terribly wrong in a country where the political party that brought Civil Rights (and African-American sports stars) loses almost every election in the South. There is something wrong when trying to insure a few million more people medically was met with devastating defeats in both chambers of Congress, where the other side has offered nothing.

America gave the world three gifts, all in danger:  liberty, the national parks, and public education.  There is a fourth gift, also in danger: a large middle class losing faith in the system.  Gobs of money are not trickling down, and they never have.  The direction of the trickle is upward, defying both gravity and logic.

YOU CAN’T EAT DEDICATION

December 22, 2014

As I rode the bus yesterday, I happened to hear the driver say starting pay was $17 an hour, about $34,000 a year.  This is a job where one has to drive a large vehicle in traffic, keep a schedule, load disabled people and strap them in, keep order, deal with the general public, who are not generally well off, often with mental disabilities, in a place with wet, icy roads.  In short, the pay is not commensurate with the responsibility.

We don’t pay teachers well, either, a similar starting salary here in Eugene.  Sure, experienced teachers and bus drivers get more, but they top out about double their starting salary, well below six figures.  Teachers have a lot of responsibility, too.  They are educating the next generation.  They have to deal behavior problems, be surrogate parents, deal with parents, and teach to standards.  I have been a substitute, where I got paid $75 a day to teach statistics, keep order, holding my bladder 6 hours, and wolfing down my lunch in 2 minutes.  I’m literal. It was 2 minutes.

Now I read that the Business Roundtable wants to delay full Social Security from 67 to 70. They wouldn’t have this affect those over 55, but if I were 50, and I had been counting on getting SSI, I would be upset.  Indeed, far too many elderly require SSI to survive, which was never the intent, but medical and other costs don’t go away.  The group wants to decrease COLA, the cost of living adjustment, as well.

The Business Group is a bunch of super rich CEOs, many of whom have annual bonuses greater than the lifetime earnings of the bus driver, the teacher, and me.  Certainly, this is often the case with financiers, who got huge bonuses for destroying the world’s economy in 2008.  Mr. Obama oversaw the recovery, which has been remarkable, but just not fast enough for people, which is not surprising, given the total lack of Republican support, and the party of deregulation is now back in power.  If we paid teachers better, more math majors might have gone into teaching, rather than Wall Street, where they created models using the assumption housing prices would never fall.

I’d bet many of the Roundtable folks say that the climate isn’t changing, too, despite CO2 levels we haven’t seen in 600,000 years.  Yet, they will say the stock market always goes up, with 80 years’ data.

The Roundtable says that personal savings should be increased.  I agree, but it’s difficult to save when one has student loans to pay off (to become a teacher, for example).   Granted, many don’t manage money well, which these rich folks count on, so they can sell stuff at higher cost, get higher interest rates on credit cards, the fine print of which most can’t understand, and push debt instruments that practically nobody understands.  You don’t believe me, watch Suze Orman sometime.  Oh, if you don’t know what the Rule of 72 is*, you have just proven my case.

I’d like to see Common Core deal with financial management.  A hundred billion dollars a year is borrowed by students.  The amount is unsustainable and must decrease.  Here are my ideas:  one, mandatory national service (not religious) required which discharges federal student debt.  Second, no cap on withholding SSI deductions. Third, stop giving people like me SSI.  I end up donating much of it in one way or another, but if you make six figures for 10 years, you delay taking SSI for 10 years.  That is forced saving.  I’m flexible on the amount.  What we must not do is make it more difficult for the working men and women, the ones who teach our children, drive our busses, pick up our garbage, clean our buildings, to retire with less.  We find another way. If others disagree, no problem.  But I don’t want “Damned liberal socialists are stupid” comments. I want specific ideas, written with good grammar, with dollar savings, and how it deals with the poor, needy, those with bad fortune, like leukemia, or accidents.  I have been fortunate, in large part because of America, and in lesser part because who I am and my work ethic.  The idea that  people are totally self-made goes against what American government has done.

The Roundtable had the audacity to want to raise Medicare eligibility to 70, not 65, which only shifts costs to somebody else.  If you are born after the mid-60s, you are SOL.  Looked at insurance premiums on Blue Cross for a healthy 65 year-old lately?  About $2K a month. We currently have the Affordable Care Act, but that could easily be gutted by Congress.  Medical costs increase dramatically with age; medical debts are a major cause of bankruptcy.  We increase the age groups that can get Medicare, not decrease it.  Where’s the money coming from?  Why from those who make over $2 million a year, with high marginal rates on bonuses.  Tell me, please, why a football coach should make $7 million with a low marginal tax rate?  He brings money to the school by using players who get paid nothing including no degree.

The Roundtable thinks “efficient” medical care will cut health care costs.  I heard about “seamless” care 20 years ago; we still don’t have it.  I espoused quality in medicine 35 years ago, because it was better and saved money, but we still don’t have good indicators. If we did, we’d easily know the number of annual deaths due to medical errors with a reasonable margin of error.  Yes, easily.  I understand sampling.

What need to expand Medicare to include the whole country, but I’d accept age groups as a start.  This approach won’t bankrupt the country or the people; indeed, Medicare is one of the best run programs we have.  The Roundtable think we ought to have competition, because “well-informed seniors” will make the right choices.

Have any of them read the Part D drug manual from Humana?  Medicare is fine; I have issues with the number of insurance companies who generate more paper than a Douglas Fir Forest in Lane County.  Well informed?  By whom?  Brokers?  The one I had steered me in the wrong direction.  TV ads?  By whom?  I am a college educated 66 year-old former physician.  I have trouble understanding the rules.  What about the poor black woman in Arkansas who turns 65?  Or an 85 year-old with dementia, an elderly person who can’t see well, can’t think as clearly as Paul Ryan thinks he can, and doesn’t have technical skills?  Do they really think “market forces” will work?

Oh, the Roundtable is in favor of healthy lifestyles, but they object to the EPA’s reducing ozone in the air.  That is hypocrisy. They are against regulations on food, water, or emissions.  Deal with obesity?  Five years ago, I measured the number of obese 6th graders in one school district in Tucson.  The results OF THE 1100 were astoundingly depressing.  We could have obtained data for the whole county, 32,000, FOR FREE.  Nothing happened. Why aren’t we using elderly volunteers more?

We need a strong middle class.  It’s time to deal with outrageous incomes that have produced no significant value.  The Waltons have $30 billion net worths on the backs of poor people working without adequate insurance. We need a major increase in the marginal income tax rate, we need a tax on investments, higher on capital gains, which are not earned income, and a buy-sell tax of 0.125%, which would generate $1 trillion by 2024.  We need a tougher means test for SSI and Medicare than we currently have.  We don’t take down Medicare or SSI for those who need it most.

The Roundtable wants better teachers, but they somehow think that certification requirements will do it, when increased pay will lead to better teachers. Increased pay works for better CEOs, I’m told, better coaches, better university presidents, so why should it be different for teachers?

My father, who went from a high school science teacher to superintendent of schools, once told me the argument “teachers were dedicated” was the reason their pay was so low.  That would be fine, he continued, “except you can’t eat dedication.”

The Roundtable ought to see if they can compute the area of their table.  If they can’t, then maybe they ought to stay silent on matters of numbers and how to save money, when not everything comes with a dollar sign.  That is the America I want and serve today.

*Rule of 72:  The time for doubling (year) is 72/rate of increase (measured in %).  Credit card interest at 24% doubles debt in three years (72/24 = 3)

Proof:  P=Po (exp)^rt, where P is the new principal, Po the original, exp=e or 2.71828, r the rate in decimal form, and t=time in years.  [1+(1/n)]^n = e = [1 + n}^(1/n)

(P/Po)= (exp) ^ rt; ln (P/Po)= rt.  (P/Po)=2 for doubling and ln 2=0.693.

Therefore 0.693=rt.  Change rate to per cent  and 69.3=rt.  72 is easier to work with.  so t=72/r.

Tripling time is 110/r.   This is done on aTI-83 by LN, 72/rate you choose.  It is easy.  This should be in common core.