Archive for the ‘MY WRITING’ 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.

THERMODYNAMICS

February 2, 2015

The first month I was an intern in medicine, we had a person with congestive heart failure who was on fluid restriction.  Despite this and diuretic therapy, the patient did not lose weight.  Maybe, he was getting fluid from heaven.  Or was he?

I decided to ask the man some questions.  What did he do in the hospital?  He took walks with his wife.  OK, good.  “Did you stop by a drinking fountain at any point?”

“Oh yes, I often did.”

“What did you do.”

His wife answered, “He took a big drink.”

When we restricted him to his room, his weight dropped and his condition improved.

At the weekly Stammtisch the other night, I got more than a German education.  One lady was talking about fire walkers, and a guy was talking about a man in India who allegedly had lived for 70 years without eating or drinking. I was polite, simply saying extraordinary claims (the second) require extraordinary evidence.  Fire walking exists, and there are reasons why people can do it.  We understand the science behind fire walking.  Don’t run, make sure the wood is dry before burning, and don’t try it on metal.

Getting one’s nutrients from the air, or from heaven, is another matter, unless one is moss growing from a Sitka Spruce on the Oregon Coast.  I hadn’t heard of people’s doing that, but these days there are so many new stories that it is difficult to keep up with them.  I decided to check online.

Indeed, such a man has claimed this.  He was checked with CCTV for 15 days and indeed did not eat or drink.  Interestingly, he was dressed while being observed.  Supposedly, he had no urine in his bladder and had no bowel movements.  I say supposedly, because maybe somebody filming him had an agenda and lied.  People do.  In addition, I did not see results of daily weights, electrolytes, BUN and Creatinine, UUN (urine urea nitrogen), urine specific gravity, if there were any, all of which would have been necessary.  If he were indeed getting nutrients from heaven, which plants do, his weight should have stayed the same. This story is an extraordinary claim; it requires extraordinary evidence, which was not forthcoming.  CCTV for 15 days is not enough.  I want to see the above.  Why?

There was no explanation of the few times the individual was NOT on CCTV, having gone to meet with his supporters.   I wonder if there were water fountains. He was dressed and could have hid a lot of food under his clothes.  I didn’t argue with the individual who told me the story.  He was equating some of this to “My Spiritual Beliefs” with a few references to Jesus.  Those arguments are un-winnable.  I was a bit disturbed that somebody would take such a claim at face value, but people do that these days.  I’ve seen pictures showing a huge eclipsed Moon from the North Pole.  It doesn’t work that way, and I can prove it, but many still believe this sort of stuff.  The local paper didn’t know that the Harvest Moon occurred annually, simple to research, a weatherman in Tucson thought local noon was at 12 p.m., which it is not,* and a different weatherman once commented that the Sun was “already” setting later on Christmas, “only four days after the equinox.”⁺ These are easily observable with the eye.  Technology is a wonderful thing, but photoshopping is too often believed; film was harder to fake.  I suspected nothing I said would convince the man otherwise.  I did mention “thermodynamics” twice, and he looked at me with a quizzical expression.

Obtaining food from heaven is reserved for plants, whose pyrrole rings have magnesium and not iron.  We can’t do this; indeed, people who have tried have lost an extreme amount of weight, had incipient renal failure, and some even died.  In short, there is compelling evidence suggesting that not eating or drinking leads to severe physiologic compromise and even death.  At the end of life, VSED  (Voluntary Stoppage of Eating and Drinking) causes death.  Why are there not survivors in this transition stage, especially given that impending death is an extremely spiritual time?

I try to be a reasonable skeptic, but here, reasonable has requirements.  “Spiritual,” and “God” don’t cut it with me as proof.  People used to call a child’s death from acute lymphoblastic leukemia (ALL) “God’s will.”  Today, 90% survive 10 years and are considered cured; half a century ago, ALL was a death sentence.  Sounds more like science to me.

I want the individual naked on a bare bed in a bare room with no evidence of food or water present.  I want the trial to be at least a month, subject’s health willing, so that possible over hydration issues or medications that were given (antidiuretic hormone, for example) can “wash out” and not be a factor.  People fake things all the time; I did a grand rounds on this for many years as a neurologist, to show how people could fake dilated pupils, paralysis and a host of other neurological conditions.

How did I know?  People who have paralysis from a stroke or a tumor do not lose sensation sharply to the midline, they do not lose smell on one side of the nose, and they don’t lose vision in the eye on that side.  Our brain does not work that way.  Those who present with a dilated pupil and coma, where fakery is a real consideration, require two things:  Pilocarpine should constrict a pupil caused by oculomotor nerve paralysis.  Drugs placed into the eye to dilate the pupil will resist pilocarpine.  As for “coma,” ice water squirted into the ear is not only exceedingly uncomfortable, but the eyes move in a way that cannot be faked. Some people want to be ill, as strange as that sounds.  I carried pilocarpine in my medical bag.

I feel the same way about UFOs.  There are many things for which we do not have an explanation.  I try to look for natural causes, rather than to postulate UFOs, Poltergeists, alien abductions, and government conspiracies (amazing secrets kept by a group of people who are often labelled incompetent bureaucrats).  During World War II, Venus was fired upon by the US from Maine when its bright light appeared over the ocean.  Our memories are fallible, they change with recall, and perceived sincerity, looks, or voice of an individual do not constitute proof. People have strange ideas how the body works.  They hear tales from their friends, see newspapers at the check out line, and assume these must be truthful.  I’m guilty of magical thinking, too. The difference is I know I am hoping for things to happen that I have no control over.

I found it interesting that the man who was so willing to believe a person could survive for 70 years without oral intake of food and water was so unwilling to believe that fire walking could exist.

Thermodynamics.

 

 

 

*Local noon is when the Sun is highest in the sky.  Not counting Daylight Savings Time, this occurs at noon only at longitudes evenly divided by 15 degrees.  For example, Tucson’s longitude of about 111 degrees is 6 degrees west of 105.  Local noon varies around the mean of 12:24.  Every 4 minutes is one degree of longitude:  1440 minutes/day/ 360 degrees of longitude/day.

⁺The equation of time is the difference in Sun time from clock time. The Sun runs faster than clock time in December, but every day it is slowing down much more than its southerly movement is occurring.  The first delays the sunset, the second speeds it up.  This makes the earliest Sunset about 6 December and the latest sunrise in early January.  By Christmas, the Sun has been setting later for nearly 3 weeks and is quite noticeable…if one looks.

SNOW JOB

January 31, 2015

I was surprised meteorologists apologized for a “blown forecast” for New York City’s snowstorm.  Here was one forecast:

January 25: The New York City area is forecast to see a foot or more of heavy snow. Blizzard conditions are possible.  Parts of eastern and southern New England, including Boston, Providence, Rhode Island, and Portland, Maine have the potential to see up to 2 feet of snow. Locally more than 2 feet of snow may fall, particularly in eastern Massachusetts. The snow will be accompanied by blizzard or near-blizzard conditions.  Forecast to see a foot or more of heavy snow.  Blizzard conditions are possible.  They did not say “probable”.

Another headline said “NYC bracing for up to 3 feet of snow.”  Later in the story, there was a comment that the amount predicted was more in the 20-30 inch range.  That is a lot less. Most of the city got less than a foot, but NYC received snowfall.  New England received what was predicted.  This is not a blown forecast.  It is taking the upper estimate, overhyping it, then complaining when it isn’t exactly right.  As a physician, the famous 44,000 to 98,000 deaths caused by medical errors every year (very out of date data, now) was rounded to 100,000, and that figure was used almost exclusively.  If one allows 100,000, one must equally allow 44,000.  Neither is good, but the example is important.

I watched The Weather Channel the night of the storm, where one of the weather models predicted that NYC would get 3-5 inches.  While that model was discounted, a model did predict the storm correctly.  

A significant weather event was forecasted and it occurred.  I think the problem is how uncertainty is handled in both the scientific and lay communities.  Uncertainty to a scientist allows for a range of possibilities, since weather cannot be predicted completely accurately, and one of those possibilities affected a lot of people.  Uncertainty to the general public too often means, “They don’t have any idea what they are talking about.”

Worse, the so-called “blown forecast” had comments from those who feel climate is not changing.  After all, the headline postulated, if you can’t predict a snowstorm 2 days in advance, why should we believe you about 100 year forecasts?  More on this later.

Years ago, a leading weatherman on the Tucson news suddenly changed his forecasts from 5 days to 7.  He had used 5 day forecasts, because he felt there was too much uncertainty out 7 days.  I wrote him to ask why he had changed.  He replied that he had been to a conference of TV Weathermen and learned that the general public wanted 7 day forecasts.

So?  Why should we accede to their wishes by giving them a lot of potentially wrong information?

There are many weather models; some are better than others for certain conditions or in certain years.  “The GFS has been trending wetter than reality this year,” is not an uncommon statement.  The other issue is with a weather system, a shift in the track of 50 miles makes a huge difference, as we have learned with hurricanes…..and low pressure systems.  Had Katrina come ashore 50 miles further east, it is likely that the surge of water from Lake Pontchartrain would not have flooded the city.  Had the current low pressure system been 50 miles closer to NYC, nobody would be complaining about the forecast, only the outcome.

There is a big problem in America about understanding probability, and it doesn’t help to have “I’m not a scientist” mentality in Congress and “math is nerdy” mentality in the country.  Weather forecast apps give exact temperature and probability of rain per hour, which to me is ludicrous.  They give exact temperatures for 10 days in the future, which is nonsense.  People believe these forecasts, because the idea of a range of temperatures is foreign to them (“can’t you be exact?”) and the fact that weather models may miss initial conditions that lead to major changes, especially when they are trying to model the ocean.

I have studied weather models 16 days in the future model rainfall in Oregon.  During that time, I have seen waffling of the models, putting high pressure anywhere from the Great Basin to the Eastern Pacific.  The storm expected next weekend, as I write, was on and off the models for several days, before the last 5 days, when it has consistently been present, but the expected severity of rainfall is not consistent.  Still, I see forecast rainfalls to the nearest hundredth of an inch over a wide swath of Oregon and Washington.  This is senseless.  Five days before the forecast discussions, I have been predicting a major weather pattern change for Oregon next weekend.  Only when the models were in agreement about 8 days out, did the local weather discussions start to mention the pattern change as a possibility.  Today, the discussion said the models were in surprising agreement about the rain event, but not exactly where it will be maximal.

Climate is very different, for all the weather changes over decades are smoothed out, and one can become quite confident what the overall picture looks like. It’s like tossing a coin.  You know that 50% of the time it will come up heads, but you could be 50% wrong on the first toss.  Do it 10 times, and the probability of exactly 5 heads actually decreases, but the probability of 4,5,and 6, are about 65%.  Already, the probability is trending towards 50%.  The probability of 0 heads is less than 0.1%.

Indeed, as you increase the number of tosses, the percentages trend closer and closer to 50%,  as to be insignificantly different.  Climate models work this way, too.  No, we can’t predict the number of snowstorms NYC will have in 2100.  We can predict, however, the range of temperature rise on the Earth and the range of rise in the oceans.  We can also predict the amount of carbon dioxide in the atmosphere.  These ranges have very high confidence, a statistical term meaning the likelihood of an unknown value, such as increase in global temperature in the year 2100, could be in a range of values, none of which is zero or negative, if we are 95% confident.   I have never seen a confidence interval (CI) quoted by someone who denies global warming is occurring.  The IPCC’s confidence has been known for years.  CIs are a scientist’s way of saying, “I might be wrong.”

Next hurricane season, look at the cone of uncertainty for hurricane motion. So many models are used that they are called “spaghetti plots.”  One could go back to the days of prayer and magical thinking, or one could look at the GFS, ECMWF, or NOGAPS, to name three. With a great deal of ease, one can have an idea of what the weather may be like several days in advance.  It’s worth learning about uncertainty; after all, it is the basis of our existence.

 

Below:  GFS Model showing precipitation (purple), heavier (blue and green) along with the 1000-500 mb thickness (one measurement of high and low pressure).  This is 6 days out, at 12 Z 6 February, or 4 a.m. Friday.  It shows that the Pacific Northwest is going to be wet, and northern California may get a strong shot of rain.  Notice the rain in the southeast and off the east coast.  The GFS has a panel of 10 days, with 1/2 day intervals.  The GFS has been showing this for several days, but the focus of the heavy rain has not been consistent.

Screen Shot 2015-01-31 at 8.04.52 PM

NOTICING THE WORLD

January 30, 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 and not clinicians, and I say that as a former neurologist who read CT head scans well.  It’s fine for a medical group to own an X-Ray facility and for clinicians to 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 so that 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, an internist once sent me a patient with leg pain, concerned it was due to a pinched nerve in the back.  The lady had pain near the knee, but it was point tender, meaning that the problem was where I was touching.  I obtained a bone scan, looking for a fracture and found a hairline fracture of the proximal tibia.  I got a lot of pleasure diagnosing something correctly out of my field.  Most specialists do.

Years ago, I was 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 which is usually due to a non-neurological problem.  The man had driven 1500 miles (2500 km) from Minnesota to Arizona. I saw him, noting he seemed to be breathing a little faster than normal. His neurological examination was normal. I obtained an arterial blood gas, since we didn’t have pulse oximetry back then, finding pronounced hypoxia.  Thinking a cardiac arrhythmia could 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 leg clots occurring during prolonged sitting on his long drive.

Several years later, one of that cardiologist’s partners referred a patient to me on whom he had diagnosed an occipital lobe infarct, producing only blindness to one side, not out of one eye.  For a neurologist, that is not difficult to diagnose, but many non-neurologists miss it.  I was impressed the cardiologist had found it.  I’m sure he got pleasure from diagnosing something outside of his field.

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 better.

So, when the MRI of my neck, done because of a concern about a pinched nerve in my neck, 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.  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.

OPIE DILLDOCK

January 26, 2015

OK, I’ll admit it, I am a little competitive about hiking.  But only a little.  I don’t trail run.  I tried to do a fast trail walk once, and it was a killer.  Like many things I do, I am good but not great.  I don’t do anything really well except maybe work with numbers.  That and a couple of bucks will get me coffee.

When I joined the Obsidian hiking group, I wasn’t sure what I was getting into, but on the first hike to Rooster Rock, climbing 2300 feet in a few miles, I stayed with the lead group.  When the other group rejoined, we had a 20-30% grade the rest of the way.  One guy led, and I just stayed behind him.  I let him go first, but I talked all the way up.  I sort of did that on purpose.  It was a nice way to say I was not in the “red zone,” that I could talk and hike up a steep hill at the same time.  I did that once on a bike, too, and I had it done a lot to me.  It’s a bit demoralizing to be completely breathless and have a guy or gal come by you talking away as if they were out for a stroll.

Obsidians at Rooster Rock. I am sitting, front row.

Later in the summer, at Black Crater, just east of McKenzie Pass,  one of the guys came up behind me, when I was leading, and I stepped aside, so he could go up.  He has been known to run up the trail, although this one was steep enough that after he opened a 100 meter gap on me, it stayed there.  I was fine with it. I liked my pace, and I enjoyed the hike up.  I really don’t need to lead, but if I am last, I want to be the “sweep,” the guy who takes care of any problems in the rest of the group.

View from atop Black Crater. Smoke from wildfires.

View of Sisters from Black Crater. Smoke from wildfires.

When it comes to my hiking portfolio, however, I wanted last summer to build my Oregon one quickly.  Still, there are trails that have yet to see my feet.  On that Rooster Rock hike, another hiker told me about some loop hike I needed to do in the summer.  He said it was fantastic, but I couldn’t remember the name.

One week, I did 4 hikes in 5 days, a lot, even by my standards.  I was a bit tired on Monday and Tuesday and took the days off.  I was going to hike Thursday to either Middle Pyramid or Browder Ridge, a couple of good, reasonable tough hikes. The following Sunday, I was going to lead an Obsidian Loop Hike, my first time as a hike leader.  As I was checking on how many had signed up for my hike, I saw the name, and it clicked:  Opie Dilldock, 14 miles, 2800 feet elevation gain, high in the Cascades.  Opie Dilldock is a high pass on the Pacific Crest Trail.

That was the hike I needed to do, except it was on the Monday after my Obsidian Loop Hike, and I was busy.  I can’t hike all the time.

I knew the hike needed a permit, however, so I checked to see if anything was available on the previous Friday or Thursday.  No.  But there were 12 permits available on Wednesday, a lot, considering there are only 30 allotted each day.  I wasn’t sure I wanted to go, but I couldn’t get the idea out of my mind.   I could scout the Obsidian Loop Hike I was going to lead and see Collier Cone.  Wow, what a loop.  Wildflowers would be out, and I didn’t know when I would get another chance.

I couldn’t really go on Wednesday.  It was too soon after all my hiking the previous week.  At 2 p.m. on Tuesday, 10 permits were available.  No problem, I thought, let me wait.  At 6:30, three permits were available.  I signed up online.  This is crazy, but a hiking portfolio is a portfolio, and I was going to hear later how great the hike was and wish I had done it.  My wife was out of town, the errands I had to do Wednesday could wait until Thursday, and I was going.

By 9:10 the next morning, I was on the Obsidian Loop Trail, expecting 16 miles, not 14.  I walked steadily and did the 3 mile wooded part to the volcanic region in 50 minutes.  So far, so good.  I found the trail after that, which had been under snow a month prior, and continued uphill to Obsidian Falls, 1700 feet above where I started.  I was about  6 miles in and had plenty of time.  Ten miles to go.

Obsidian Falls

Obsidian Falls

Or so I thought.

The trail dropped about 100 meters, which was a little discouraging, because I knew I would have to climb it and more.  On the other hand, I was seeing alpine lakes that in July were just beginning to thaw.  The place where I climbed in snow was somewhere, but it sure wasn’t on the trail I was on.  I hadn’t seen any of this trail back in early July.

I left the Obsidian Loop portion and headed down more and then upwards, toward Collier Cone.  I was in volcanic area now, soil like rocky ball bearings, slippery, as I started some serious switchbacking up.  It reminded me of the Grand Canyon.  Snow was to my right, and after a long climb, I saw what looked like the top of a ridge. I crested the ridge, and—wowwww— there was Collier Cone, a lake, two glaciers calving ice bergs into it.  I was 10 miles into the hike, had lunch, and figured not only would this hike be more than 14 miles, it would be more than 16.  A lot more.  I still had to get to Four in One Cone, 4 1/2 miles from the road, which led back to the original trailhead.

Collier Cone, 7200 feet (2200 m.). It is 2400 feet above the starting point, and there is a lot of downhill, so the total elevation gain is more than 3000 feet (900 m)

Collier Cone, 7200 feet (2200 m.). It is 2400 feet above the starting point, and there is a lot of downhill, so the total elevation gain is more than 3000 feet (900 m)



Mt. Jefferson

Smoke clearly visible.

Pacific Crest Trail north of Opie Dilldock pass, looking north.

Pacific Crest Trail north of Opie Dilldock pass, looking north.

Time to get moving.  I was soon on the Pacific Crest Trail, a hiker about 1/2 mile behind me and three ahead of me.  I caught up with the latter at the Scott Trail, my route back to the road.  The PCT hikers had “the look”.  It is hard to describe, but it is the stare of somebody who has been on his or her own for a while, seen things the rest of us won’t, has had a rough time out in the wilderness, but wouldn’t have it any other way, and is doing the hike for a reason, usually private.  I know this, because I have section-hiked the Appalachian Trail, and I’ve had “the look,” too.  I had seen things others never would, been hot, cold, wet, dry, exhausted, exhilarated, happy to see people, happier to be alone, hurting, not hurting, and caring only for my body and my gear, in that order.

Time to get back to the car.  I walked past Four and One Cone, where I had been 4 days earlier, back on familiar trail, found a shortcut to the car, and finished in under 6 hours.  I didn’t care about my speed.  I saw a lot.  It was a tough hike but a good hike.  I would get some junk food on the drive home.

Opie Dilldock is now part of my portfolio.  Really, really good hike.

All nineteen miles of it.

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.