Archive for the ‘MY WRITING’ Category

CREATIVITY: MUSIC, ART, CHEMISTRY, AND THE ABILITY TO SQUARE A NUMBER MENTALLY THAT NO COMPUTER ON EARTH CAN DO.

December 14, 2013

The other day, I went to a Christmas party held by a financial group who helps me deal with the morass of American finance.  One of the people in the group was a member of The New Christy Minstrals, a group that goes back to “my era.”  I was impressed.  He has entertained in each of the 50 states.

The party was held at an auditorium, and I had no idea what to expect.  I had a 1300 mile drive ahead of me the next 2 days, and I didn’t plan on staying more than a few minutes.

I stayed more than an hour.  Members of the group had made a band, and other employees danced when asked to appear.  It was wonderful.  My advisor was one of the musicians, and he knew the history of jazz and American music from a century ago.  I learned that “Barbecue” was once slang for “pretty woman”.  I didn’t know that.  When I open my mind, I learn a lot of things, which help me become smarter.  A lot of people call me young, but at 65, I am old.  I happen to keep my mind tuned to new things and try not to disparage or remove them from thought because of my preconceptions.

I listened, and I enjoyed.  I listened, and I started writing, in my head kind of writing, things that the music evoked in me.  What I was seeing on the stage did not evoke an article at all.  It just made me think. Five days later, what I saw on stage became, in five minutes, an article.

Writing is a lot like music in that regard.  Musicians sometimes “get a song” in their head and start to write and polish it.  Sometimes, they have jam sessions, feeding off one another.  A solitary writer like me can’t do the latter, but I feed off of what I see, almost never at the time, but days later, when I didn’t even know the initial moment was special.  I happened to see a video on Facebook that showed South American children making instruments from stuff in a landfill.  That reminded me of music,  the advisor  playing it, how I admired his creativity, and I started to write. There is a story in a lot of things in life; sometimes, it takes another story or an incident to trigger them.

I write.  That is creative.  Oh, it doesn’t bring people to the blog very often, but it allows me an outlet, just as much as the guy who plays on a city corner JUST FOR THE SAKE OF CELEBRATING LIFE BY PLAYING MUSIC.  I write for the sake of celebrating life by combining words and punctuation in ways they have never been combined before.

I never looked at myself as creative, because society often defines creativity as music and art.  That is wrong.  Every writer is an artist, and every artist a writer.  Both are creative.  So are mathematicians, statisticians and chemists, too.  Society calls mathematicians nerds, and it is acceptable not to be good at math.  Statisticians ask the right questions and help design (read: create) studies, and chemists create new compounds.  In 1970, I created ortho-phenyl benzhydryl chloride.  It never existed before, except in theory.  I made it.

Tell me, is it not creative to be able to multiply any pair of two digit numbers in my head faster than a calculator?  Is not the ability to do this in three different ways creative?  Is not my ability to have discovered arithmetical tricks that I have never seen in books creative?  Is the fact that I found the pattern for MENTALLY, NO CALCULATOR NEEDED squaring any number that is all 9s*, that no calculator on Earth can do, because it doesn’t have the space?  Or that I can square any three digit number ending in 5, as well, faster than anybody can with a calculator?

I write, because if I write well, I read it over and over again.  Not all my posts are that way, but some are.  Some of my words are so powerful to me, that I tear up when I read them.  That happens with music, and it happens with writing.

Inside all of us is some streak of creativity.  I hated it when somebody said, “We are all musicians.”  No we aren’t.  He was, but I was not.  What he needed to say was, “We are all creative, should we look deep inside ourselves.”  That is true.  We may not make a living at the creativity; my finance guy makes his living dealing with finance, but he makes his life, I would bet, from music.  It defines him, and it shows his celebration of life, just as my writing celebrates part of my life, just as an orthopedic surgeon’s work mending a broken hip celebrates hers, a trucker who knows how to back an 18-wheeler into a small space efficiently celebrates his, or a horse trainer who can without anybody seeing anything being done make a horse do a flying change and a half pass.

These manifestations of creativity have to be seen to be appreciated. I discover that my creativity sometimes lies in areas that I least expect.  I never expected to become a decent writer; I became one.  I never expected to do some of the things I do, such as canoeing all over the North American wilderness.  The ability to maneuver a canoe, to shoot rapids, to put it on one’s head and portage it, making it look so easy that anybody thinks they could do it, ah, that is creativity and the celebration of life.  It’s not a competition, it is a celebration.

Very blessed are those who can make a living from their creativity.  Very human are those who make their lives from their creativity.

9*9=81

99*99=9801    A nine, an eight, a zero, and a one

999*999=998001   Two nines, an eight, two zeros, and a one.

9999*9999=99980001

9 (n times) * 9 (n times)= 9 (n-1 times) 8 0(n-1 times) 1

I found playing the piano difficult.  I found this pattern in about 2 minutes.  Do I make a living from this?  No.  Do I celebrate life from it?  Oh yes I do.

 

DEAR BUSUU, LIVEMOCHA, ROSETTA STONE, DUOLINGO, AND PIMSLEUR: THERE IS NO FREE LUNCH

December 8, 2013

Quite by accident, I started to learn German while with many Germans on an eclipse trip in 2010 to Patagonia, Argentina.  They were nice, and two women became–and still are–good friends. I promised them if they came over for the 2012 annular eclipse in Arizona, I’d learn a little German.  They didn’t come, but I started learning German–at 61. 

I started with Rosetta Stone (RS).  I saw the ads, I talked to a person in Sea-Tac, where I tried a few words, and I thought this would help.  I was so motivated, that after I finished Part 1, I decided to repeat it.  In 3 months, I went through all 5 parts.  That is motivation. RS has good voice recognition software, and that is its strong point.  One will be able to say words reasonably well enough they might be understandable.  For a short trip to Hungary, RS would be great.  Unfortunately, RS failed to discuss grammar, which would have been easy, nor did it discuss the importance of learning gender and plural with each German noun, which is both essential and easy to do.  German children know the noun genders by 5; those who learn the language must memorize each noun’s gender and plural.  I learned verb in second position gradually, and placement of the verb at the end of a subordinate clause, but these could should have been discussed, rather than having my noticing where they were.

I wonder whether independent and dependent clauses have gone out of fashion in language teaching.  I am a believer in language for communication, but there is also a place for understanding basic grammar, including adjectives, adverbs, and prepositions.   If people aren’t interested in these, then they aren’t interested in learning the language.

I want to be clear: one may learn to speak some words in a language, but I do not consider a person fluent, until one can speak, understand, read and write anything in that language.  With a 500 word vocabulary, one can speak a few phrases.  That is not fluent.  I have learned nearly 1000 German adjectives, 1500 nouns and at least that many verbs.  These are essential in every language, and without knowing them, one will not be able to piece together a conversation.  Every word I learn may be a key piece of a conversational puzzle.

I bought several German grammar books, which were difficult and failed to explain what to me many subtleties I needed to know.  Incredibly, for a year neither one person nor any book explained why “Ich bin einen Mann” was wrong and “Ich bin ein Mann” is correct.  The first is wrong because “to be” takes nominative case in German, as does English, and “ein” is nominative, and einen “accusative,” or objective case for a masculine noun, which Mann is (incidentally, the fact that girl, das Mädchen, is neuter, was never discussed, and one learning the language might be curious as to why “girl” is neuter.  Hint: it is the ending).  In English, we say: “It’s me,” for example, rather than the proper “It’s I.”.  In German, nominative case is always used after “to be”.  This is basic, easy to understand, and yet many native speakers could not explain it to me.  I discovered the explanation one day while running, which by the way, is how I learn, which brings me to my next point.

I am annoyed when people tell me how I learn.  I don’t learn like a child.  I think that a 5000 word vocabulary is what I need. Furthermore, adults learn in a variety of ways, and I learn in a way much less common than most American adults.  I know how I learn; indeed, my knowledge got me through graduate school, 30 years after I had last studied calculus.  Nobody can learn a language in 20 minutes a day, I can’t learn it by translating Wikipedia, and I can’t learn it, it appears, from anybody except the best teacher I know.

Myself.

Yes.  I am a natural teacher.  I have taught at least 10 different subjects.  I could tell people how to learn German, even though I am not fluent in it.  The first rule is that there is no free lunch.  Want to speak German, or any other language?  You can, but be prepared to work…..a lot, unless you are immersed in it by living in the country, and even then there are people who have trouble.  German is difficult.  The second rule is not to argue with the language, only with the speakers.  I never once asked why German adjectives have endings.  They do. Or why nouns ending in -ung are feminine, nouns that are verbs without the ending are masculine, or infinitive nouns neuter.  They are.

Occasionally I found a good grammar site.  From one, I learned how to deal with adjective endings in German, which are almost incomprehensible to understand in the dozen grammar books I read.  There, I found a way that improved my getting the right ending from about 25% to over 95%.  Do I need it?  I think I do.  I’d rather hear “He and I” in English rather than “Myself and him,” although I understand both.  If I need to learn something, I want to learn it right.

I wrote the author of the site to thank him, and he told me about LiveMocha, like Facebook for language learners, with people helping each other. I became one of the top 100 English reviewers on the site, so I was giving a lot of my own time to others.  I used an internationally known company to find a teacher for me in my city.  I did not want to take courses at a community college.  I was motivated and I was willing to work hard with a guide. Incredibly, in a city of a million, the best I could find was a woman, nice enough, but whose credentials were that she spoke German and had lived in the US 27 years.  I spent the first day trying unsuccessfully how to pronounce die Bücher, the books, in German.  During, the second meeting I learned that she had never taught German.

Over time, we ended up speaking to one another.  I learned a few phrases, but when I asked why, she replied, “That’s how we say it.”  That is not how I learn.  German, for all its difficulties, has rules.  I found nearly all on my own.  On LiveMocha, I took its free courses and did the paid Activ Deutsch in 3 months.  My comments were often grammatically wrong, and I was told how bad my accent was.  That is not how I learn, nor do I don’t believe it is how most people learn, by being strongly criticized, and I have taught everything from English to clinical neurology.  I did far more than the exercises asked for.  I wrote the maximum 1024 characters, and for the spoken part I made up stories that were far more complex than the 30 words we were asked to say.  I was motivated.  I didn’t care if I got 2 stars out of 5; I finally blew up one day and asked all reviewers whether they could understand me.  They could.  Americans are far more tolerant of non-natives who speak English than the reviewers of me whom I met on LiveMocha.

I corrected English exercises, explaining why I made the corrections I did.  I pronounced words slowly, rather than at full speed, and I wrote out the phonetics of pronunciation.  In short, I did everything that I wanted to be done for me.  I was in strong demand as an English teacher.  Sadly, my learning experience was at best sub-optimal.  I asked about zu- constructions, common in German, and got no answers.  None. I found grammar books very poor in explaining these, so I learned them on my own, by studying patterns when I saw them.

Not one grammar book I have seen discusses the importance of separable and inseparable prefix verbs, how often they change the meaning of a verb, often have multiple meanings, and how a minimum of several hundred must be memorized.  This oversight absolutely stuns me, and frankly makes me wonder whether German can be taught to non-natives who don’t live there.  I am currently testing that theory, and I have been testing it for three years.  The results are not in. I once saw discussion of 11 different prefixes to the verb lassen=to let or to leave, not ordered.  On my own, I have learned 20, 7 separable and 13 inseparable, which is how one needs to learn this.  I found the information over time, myself, and it was daunting.

I spent 3-6 hours a day learning German, receiving a certificate in 2011 saying I was fluent.  I wasn’t.  I went to Europe for a month, forcing myself to speak only German, no matter what was spoken to me.  I left, being advanced beginner, or A2.  I almost quit trying completely when, on a tour in Austria, I could not understand the guide at the Eishöhle, or ice caves.   I traveled to Switzerland, and can attest that every German I have met says they can barely understand Swiss German. Indeed, I’ve actually heard it translated to regular German on German TV.  Austria and Bayern have dialect, the latter  so strong that German TV often uses subtitles for many shows filmed there.  I came home discouraged and almost quit.

I wrote a few people, but correspondents in German weren’t exactly dropping out of the sky, despite the fact I was corresponding with people in at least 20 countries in English, helping them.  Bluntly, I was giving much and getting little back.  I finally realized what I needed to do was what I did throughout high school, college, medical school and graduate school.  Teach myself.

I knew it would be difficult, I would probably never be fluent, but I could learn the language reasonably well to appreciate it and the German culture. While I knew good teachers existed, I gave up finding anybody who taught the way I did, with interest, patience, explanations, and time.  I investigated the Goethe Institute, and they said (for a rather large amount of money) that my course would be 18 writing submissions.  I write German fairly well.  I needed to speak, not write.

I read German books (to the wall, so I could pronounce the words) and wrote down every word I didn’t know, looked it up, made lists, and went through the lists day after day.  I started listening to German television shows, 1-3 hours a day.  It was free, and day to day German, not child speak.  I immersed myself, and indeed, some days I hear more German than English.

Eventually, the vocabulary I learned started to help.  In 2012, I found 2200 new words and knew 2/3s of them.  Now, I estimate my vocabulary at about 3500 words, and TV shows make sense.  I have trouble with plots, but I have that trouble in English, too.  I listened; I realized that if I translated, I would miss things, so I try to get the sense of the conversation.

One day, I understood an entire show, plot and German.  It was wonderful.  It has happened since 6 other times, not often.  Shows from Bayern are difficult.  From Austria, they are not much easier.  From eastern Germany, where I am told they don’t speak clearly, I understand the most.  It just is.  From the Ostsee coast, I can understand fairly well.  The Herzkinos (romances) are clearly spoken; I understand almost all of them.

There is a blog I follow, but there is too much emphasis on flavoring particles and sounding German. I don’t want to sound German.  I want to speak German, read it, write it, and understand it.  This is what is happening to English, where more non-natives now speak it than natives.  Indeed, when I help a Russian woman with English, we often communicate in German, because we are both intermediate speakers.  I don’t get heavily criticized for not being fluent, I am understood by her and she by me.

I live in a land with a lot of diversity, many are not natives and natives often have poor grammar.  We deal with it here, because to many of us communication is more important than grammar, when it comes to a non-native speaker.  But natives who teach must understand their language’s grammar.

Will I ever become fluent?  Probably not.  I’ll get better, but it won’t be from all the great ads and new methods of learning that I hear about.

It will come the old fashioned way.  From hard work and earning it.

PART D MEDICARE. FIRST TEST: GRADE D.

December 4, 2013

I apologize to those waiting at Wal-Mart on Wetmore for their prescriptions, while I was on the phone tying up one of the pharmacists.  I know I was inconveniencing you, because she eventually said she had a long line of people waiting, so I got off the phone, in order to give her time.

What happened?  Bad system.

Why?  Good question, and easy to answer, because in large part, nobody in Tucson listened to me when as medical director of a hospital, I said we had to fix bad systems, not punish bad people.  Since then, bad systems helped speed the demise of both my parents and affect every other member of my small family’s medical care. I’ve been through all of that in prior posts: I will stick only to the current problem.

I am on Medicare and needed to sign up for Part D drug benefits. I went online and decided to do it through Humana, which meant Wal-Mart and not CVS.  OK, no problem.  I can drive, rather than walk, to get my medications.

On the Web site where I went, it asked for what year.  I checked 2014, since I wasn’t interested in 2013.  I MADE A MISTAKE.  Or did I?  I was born in December, so I went on Medicare on 1 December.  I needed to sign up for a 2013 plan (December), then sign up for a 2014 plan.  I am quite certain this was not made clear.  The broker whom I used for my supplemental did not make this clear at all.  I am certain of that.  I was told it would be “easy to do”.  What I was not told was, “You have to take care of 2013 before you do 2014.”

Watch what happened.

I signed up for 2014, and I got a lot of paper with an ID card for my 2014 plan.  In the paper, which I try to read,  I learned my drug plan began 1/1/2014, so I said, “Uh oh.  I need coverage for December.”  I could have just paid for it on my own, since I take very few prescription medicines, but that assumes I stay healthy in December and not need a lot of high powered drugs for a ruptured bowel, a traffic accident when I drive to Oregon, or a host of other possibilities.

I called Humana.  I was transferred four times, the fourth back to the original person.  I finally had to explain to them clearly that I was a first time user and not changing my plan.  This is a problem I find far too often in this country.  There is an implicit assumption made, whether it is your car getting fixed or having major surgery, that each person innately understands the key vocabulary.  I did not say the right words, which were, “I am NEW to Medicare.”  That cost me about 20 of the 66 minutes I would spend on the phone.  I explained diagnoses to people.  I explained treatments.  Whether people listened was another matter.  Back then, there were a lot of complaints about how long doctors let patients talk (18 seconds) before interrupting.  I never heard how long patients let ME talk, before interrupting (5-10 seconds).

The next 25 minutes were spent giving out all my personal information, which at least was easy to do.  That led to the last 21 minutes, which was a “phone signature,” which I had never done before.  I have seen 14 total solar eclipses, traveled to 48 countries, published 60 articles, and am well on my way to being bilingual, but I do not know what a phone signature is.  Eventually, that was explained, and I hoped that the telephone system would not crash the whole time I heard a lot of words and had to remember to say “yes” after the prompt.  Starting over was not an option.  I then was accepted, and got the 2013 paperwork, which I added to the 2014 paperwork.

Later, I got another call, this time from Cincinnati, Humana’s headquarters.  Because I had signed up for 2013, now my 2014 plan was invalid, so I had to reapply for 2014.  That was easy, since I had done it before.  The one good thing was that I had a telephone number to call if I had trouble.  I had no trouble.  Why I kept the phone number, I don’t know, but I often save things, although I have trouble finding them later.  Again, I will be sent the same volume of 2014 paper coming, because I originally signed up for it.  This country runs on paper.

On the first of December, I took to the pharmacy the letter that later arrived from Humana, which explicitly stated I had coverage.  The pharmacist at Wal-Mart was efficient, and I inconvenienced virtually nobody.  I was set to get my first Medicare prescription on the sixth.

On the third, I got a call from Wal-Mart, saying my prescription was not ready, for I was not in the system.

I didn’t get incensed.  I was mostly disappointed in that I couldn’t find all the necessary pieces of paper. I thought computerization was going to do away with paper; it has increased it vastly, until recently, when with great fanfare companies send electronic prospectuses and tout how many trees they are saving. I think a prospectus ought to be limited to the following: “we can take all your money, and there is nothing you can do about it.”  But back to Wal-Mart, where I’m keeping people waiting.

I gave all the numbers I needed to, but there was still a problem.  As I saw it, once I cancelled 2014, somewhere in the system 2013 was cancelled, too.  At that point, the pharmacist begged off to serve other people.  I didn’t blame her.  Had I been waiting, I would have been annoyed, too.  Sorry, folks.

Somewhere, in the pile of paper, I got lucky and \found the number in Cincinnati.  I called the woman, told her my problem, and she said I was in the system.  So, I can only think that Wal-Mart hadn’t called.  I can’t think of another reason.  I called Wal-Mart back and gave them the number in Cincinnati.  This at least will save the pharmacist time, since the person (1) will know about me and (2) will assure her that I am in the system.

I have to hope the two of them don’t comment on what a bastard I was to deal with over the phone, a retired physician, whom nobody listened to when he discussed broken systems, a bitter old man, but one who WAS ultimately right, who ONCE again had to find the short term fix.

Welcome to American medicine.  Part D, by the way, is not Mr. Obama’s fault.

ÄRZTEPFUSCH

November 25, 2013

A German movie made me cry.  It was the first time I had ever cried because of what I saw in the language I am teaching myself.

The movie:  Engel der Gerechtigkeit Ärztepfusch, or Justice Angel for Doctor Screw Ups, I found exceedingly moving.  The ending was beautiful. I knew music could be powerful; I had no idea the effect it could have on me. I was in tears, and I didn’t care.  I cry, and when I let go, I feel perhaps more human than at any other time.

I’ve seen the ending at least 40 times.  For the next week, it is on zdf.de (24 November).

The movie opened with a woman standing in the middle of railroad tracks, wondering whether to commit suicide.  Later, we learn why, as she comes out of the shower, learning that she had breast cancer, and the wrong breast was removed.  She had therefore a double mastecomy, brief clips being shown of ugly scars where her breasts once were. The woman had to pay for the surgery, had no recourse to justice, until she finally met the lawyer.

The hospital stonewalled, saying the doctor was Spanish, didn’t speak German, and no longer lived in Germany.  The fact that nobody else spoke up, in the OR or anywhere else may be surprising to some, but the culture of silence of medical errors in Germany may parallel that here in the US, where I saw errors hidden, denied, and blamed, in some instances, upon me, as medical director of a hospital.

Back to the movie:  at the end, the lawyer for the woman said she would go to the press before the end of the day.  The hospital administrator said that he would allow the breast reconstruction, but no blame was to be levied.  The lawyer started to think, then smiled, and the music began.  The lawyer walked to the dry cleaners, where the woman and her husband worked.  In the crowd of people waiting for clothes, the woman spotted the lawyer, who had a smile on her face.  The husband, working, looked up, surprised.  The woman said, “Enschuldigen Sie mich, bitte” (excuse me, please) and came to the lawyer.

“The operation will be next week. The papers were signed.”  The woman was stunned, the music continued, as the woman broke down and hugged the lawyer.  The smile on her husband’s face was wonderful.  It was an incredibly powerful scene.

I saw three cases of wrong side surgery during my time as Medical Director of the hospital–the wrong knee, the wrong side of the colon, and the wrong side of the brain.  The last, I had to explain to the woman’s friend, since the woman had no family.  The internist taking the case wasn’t told and was so angry, he signed off the case, without finding another physician.  This unethical practice was not uncommon where I worked, where it meant that I had to find somebody–sometimes myself–to take over.  My colleagues never sanctioned the physician.  Indeed, at a Medical Executive Committee meeting in 1998, one blamed me for taking care of a patient who had no doctor.  I left the meeting, went outside where nobody could see me and cried.  That is the medical culture I was part of.

I was told by the head of the OR that 99.9% of the cases had no problem.  No, I retorted, it was 99,99% of cases, and per cents didn’t matter, counts did.  There are certain things where the counts should be 0, not a high percentage of successes.  The hospital administrator used the same words, and the lawyer pointed out 160,000 cases of errors and 20,000 deaths in Germany every year.  Wow.  They count.

Medicine here never really changed.  We have at least 20 wrong side cases annually nationwide.  True to medicine, everybody began his or her own process for ensuring safety, which of course meant in some places the proper limb or breast was marked for surgery, or the improper one was marked.  This leads to confusion as well.

When I objected to just a letter being sent to the neurosurgeon, I was told I was no longer welcome to attend department of surgery quality assurance meetings.  At first, I was incensed, because I knew about systems, and my knowledge should have been desired, not forbidden.  I also had discovered our carotid endarterectomy complication was far too high to warrant surgery.  I literally was screamed at, when my data were presented. My patients got statistics, probability, and my recommendation; other patients were not told of these risks.

After I left medicine, my mother refused a CT scan after a fall, and we were not told of the refusal  When she later died of dementia, we discovered during her final illness that originally she had refused the scan.  I was furious and published an article about it in Medical Economics.  My father, before he died, had weeping edema, swelling so bad that it went through the skin of his legs.  The nurses called it a weak heart, when in fact low protein in his blood caused the problem–simple osmosis.  Had he been diuresed, he would have become hypovolemic and died.  He did die, but from pneumonia.  I had to tell the Nursing Home Director that I was not the enemy, but I was trying to be my father’s advocate. My oldest brother had a brain tumor missed, causing him blindness in one eye.  He was a professional photographer. I had a medical error occur in me.

Engel Gerichtigkeit was only a movie, but it was powerful and beautiful; the medicine well portrayed. 

In 2001, I developed a reporting system for medical errors. Sadly, I was naive enough to believe I could implement it.  Looking back, I didn’t have a chance against the entrenched system of hospital and medical associations.  I wrote legislation for two years for the Arizona House, with 10 co-sponsors but went nowhere.  Doctors shunned me.  One response was, “We aren’t like aviation.”

“Yes, “ I replied. “Aviation deals with their problems honestly.  You sweep them under the rug.”

ARCHAIC WORD

November 21, 2013

In order to understand what follows, one must know that within seconds, I can go to the garage and find thank you notes written to me in the past 40 years, when I practiced medicine.  These notes were handwritten, a word that has almost been extirpated from the English language, now that we have the noun/verb e-mail.

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

It surprised me that day in Eugene.  I headed out for a 5 k run, a daily occurrence, and 200 meters into it, I got a sharp pain in my right patella.  It wasn’t too bad, but it bothered me, for I have never had problems with my knees.  For sixty-five years, they have climbed mountains, hiked Alaska, carried 65 kg down the middle of a Canadian river, walked thousands of kilometers, skied tens of thousands, pedaled a hundred thousand, bent as I drove more than a million, and been my friends.

I finished the run, but the knee hurt.  I took some anti-inflammatories and walked 3 km to dinner and then back.  I shouldn’t have done it, but I refused to believe my knee was betraying me.  I walked, but neither my knee nor the rest of me was happy.

The next two days, I didn’t run, but I still walked to dinner.  I was a little better.  OK, I thought, this is good.  I hiked 16 km with 300 meters elevation gain with virtually no pain.  I was happy.  I drove back to Tucson and ran 5 k again.  I was fine, until I returned home after the second day’s running.  The pain was back.

I stopped running.  For a half century I have run on a regular basis.  I think perhaps 5 times I have had to stop for some time, never for knee pain.  For the next three weeks I walked and walked, took anti-inflammatories, and my knee improved.  I was going to Uganda for the eclipse, and I did not want a bad knee to hurt the trip.

Shortly before I left, I decided to test my knee by running a few steps on it.  I am capable of remarkable denial and irrational thinking.

The third day of the test, all was going so well that I ran 60 steps three times.  I did fine.  I wish I hadn’t done a fourth.  The pain was back, and I was soon on my way to Uganda with tight connections and a bad leg.  Fortunately, I did well on the trip, because I was sitting in a vehicle most of the time.  But one day, we walked in a rain forest up and down hills.  The pain was back.  When I arrived in Houston on the way home, I took an escalator rather than the stairs.  I NEVER take escalators voluntarily.

Before I went to Uganda, I did have the good sense to make an appointment for after the trip with an orthopedist whom I have known for 30 years.  I figured I would not need the appointment; I thought I would get better.  Suddenly, I was really glad I made it.  My knee was stable and not swollen, but all sorts of things went through my head.  Could I have torn something?  Do I need an MRI or surgery?  Will I ever run again? What is going on?  A former physician, these thoughts and others went through my mind.

The orthopedist entered the room and asked if I had been hiking.  Well, sort of, until recently, I replied.  He listened to me carefully, nodding like he had seen this before.  He had me lie down and put my knee into full extension.  I had done this, but I did not have long enough arms to do what he was able to do.

OUCH!  He found the spot I had been searching for.  “Patellofemoral syndrome,” he said, rather nonchalantly.  “I’ll inject it and give you some Sulindac.”  Wow, that was quick.  He injected, without saying whether it would hurt, because he knew it wouldn’t, said he was done, and told me what to do.  From start to finish, the entire procedure took 10 minutes.  Maybe.  The pain was gone.

The physician is an elder.  He has been practicing for as long as I did plus an additional 20 years since I quit.  He has seen this condition many times.  I wish we could capture his experience and use it in the medical community.  He did something simple to him, an everyday procedure, but to me his reassurance was immense.  I never felt I did much of that as a neurologist.

But then I thought about that feeling a little more.  Early one morning, a quarter century ago, the same orthopedist called me and said he thought he was having a stroke.  He had horrible dizziness and asked if I could see him soon.  I told him to come into the office right then.  I practiced in reverse order.  If I and the patient were both ready, I saw the patient, and the paperwork came later.  Patient care came before paperwork, if I had the choice.  It drove my receptionist crazy, but I wouldn’t have done it any differently.

I knew what the orthopedist had before I had hung up the phone: positional vertigo.  I confirmed it in the office, reassured him, and was fortunate in retrospect that he didn’t need vertigo exercises, which hadn’t yet been invented.  He had no stroke, didn’t need a CT scan, and MRI wasn’t around then.  I had seen this condition a lot.

He was reassured.  I doubt he remembers that day, but you know, unless I tell him thank you for what he did, he will never know how much I appreciated what he did for me.  I will remember this day, and I will make sure he will, too.  I’m not completely sure what I will do this holiday season.  But I know I will handwrite a thank you note.  No e-mail.  The verb is “to handwrite,”  archaic today, which while sad, enhances the strength of the verb.  Oh, does it enhance the strength.

If the orthopedist is like me, he will save it.  Perhaps it may make his day, as he made mine.

BUT I WORKED SOOOO HARD!!!

November 19, 2013

In late September 1966, Dr. Taylor passed back the first paper I wrote in his English 1 class.  I had worked hours on this paper, written 15 drafts, back when we used typewriters.  Each draft was poorly written.  I can still see the angle of the red “E” on the paper.  I was devastated.  

“But I worked so hard!” is what I told my stunned parents. That paper alone kept me off the Dean’s List for the only time in my college career.  I got a C minus in the course.  I got an A in English 2.  One of the reasons I like science and math is that subjectivity is less an issue.  I did not suddenly become a good writer by the spring of 1967, any more than I was such a poor writer in the autumn of 1966.

Spring 2003.  I am teaching a statistics class for business students in Nogales and give  a group a B on their presentation.  One man said: “But we worked so hard!! We deserved an A.”  I explained that while hard work is a virtue, such does not itself deserve an “A”.  Results matter.  For every Olympian, there are hundreds of others who worked just as hard or harder but didn’t have the ability or the time, got hurt, had a bad day during the trials, and didn’t make it to the top.  Hard work is necessary but not sufficient.

I worked for years to become a better writer.  It was never a goal of mine, but I discovered that I communicate better by writing than by speaking.  I have published 60 papers in 9 different fields; won two writing awards; been an astronomy columnist for the newspaper for 20 years, writing nearly 800 columns; and been a 9 year columnist for the medical society.  I have  240 posts on my blog.  I’ve written several op-eds in the newspaper, and 75% of the letters to the editor I write get published.  I am a writer.  I am not an exceptional writer, but I am good.  Last July, my letter to the editor appeared in The New Yorker, not easy to do.

I’ve heard hospital advertisements saying how hard their staff work to care for patients.   I assume people work hard.  What I do want to know is should I get operated on, and I’m a clean case (no bowel perforation or gun shot wound, for example), my likelihood of a wound infection is less than 1%, not 4%, which it was in the hospital where I was medical director. Hard working people who work in bad systems deliver hardship.  A hospital that has a 3% higher wound infection rate for 10,000 clean cases a year has 300 more wound infections.  The human cost is significant in longer hospitalizations and possibility of permanent complications, including death and lawsuits.  The cost of these 300 infections is several million dollars.  Yet we still argue that quality costs money. I said twenty years ago, in vain, that quality saved money.

I worked hard to get my Master’s in statistics, and while I obtained it my hard work didn’t substitute for my inability to become a successful statistical consultant.  I trained hard to be a platinum bike rider, to complete the 112 mile El Tour de Tucson under 5 hours, and I missed it by 7 minutes.  I worked as much as many of the riders who beat me.  I achieved my potential, and it was less than theirs.

The concept that hard work is all people need to do to escape poverty annoys me.  Mitt Romney’s son got $10 million to start his business.  Very few of us get that “seed money.”  Many connections get some kids into the top schools, where they meet other people, network, and get good jobs.  It isn’t all hard work.  Some is genetics; there are some very talented people.  A lot of it is networking.  If one is good at networking, one will do better than somebody like me, who is not good at it.

I knew David Levy nearly 30 years ago when I was an astronomy columnist for the paper and he had yet to discover his first comet.  David discovered his first comet and had the personality that led to his connection with Eugene Shoemaker.  That led to Comet Shoemaker-Levy and Mr. Levy’s becoming famous.  I was dismissed from the paper with hardly a “by your leave” in 2004, after 20 years of writing.  Networking….and luck.  No comet in 1994,  no fame.

A Nurse’s Aide who is a single mother works hard on the night shift in a nursing home.  She does things that would repel most.  I know, because I have helped these women change soiled patients, dress bed sores, try to get the patients out of bed, and dodge blows that demented patients throw at them.  She makes a little more than minimum wage, but she works hard.  She might not have been born with great intelligence, and she might not have done well in school. Many of our politicians weren’t great students.  Vice President Dan Quayle couldn’t spell “potato.”  Arizona’s governor didn’t go to college. But these NAs aren’t blue bloods.  Yes, I wish they hadn’t gotten pregnant, but the Republican Right is trying to defund Planned Parenthood, which will exacerbate the problem.  We all make bad choices.  These women are going to be poor all their lives, no matter how hard they work.

Achieving success requires many factors, in addition to hard work and intelligence.  It is being in the right place at the right time, knowing the right people, and a lot of luck, too.  A lot of luck.

A country that pays rock stars, athletes, and entertainers millions of dollars, most of which is taxed at far too low a rate, has its priorities wrong.  A country where financiers who only move money around and collect fees ought to tax their bonuses, which annually are more than I earned in my lifetime, at 80%.  Teachers provide more value than these people, and research has shown that.  I have forgotten what rock concerts I have seen; I was lied to by financial advisors about the economy in 2007, and the list of sports stars who went bankrupt is long. I can still remember the name of my kindergarten teacher, my high school math, chemistry, and physics teachers, all of whom had a profound effect on me.

No, Mitt, and Sarah, and an especial NO to Ted and Rand; most of the millions of poor people in this country are not lazy.  A lot of them have decent ideas, want to work, and want to work hard.  If you think hard work is all that is necessary, then start with yourself in Congress, by working hard for THIS country, rather than your petty party. Your behavior is shameful, and if I were a believer, I’d call you horrible sinners.  When a person fails to achieve his potential through his own behavior, that is a shame.  When another prevents him, deliberately, from achieving his potential, that is …. I don’t have the word for it.

Perhaps if I were a better writer or had the right connections I’d find that word.

NO MORE PURPLE RIBBONS

November 15, 2013

THE “10 AND 18”

Ten Standard Fire Orders

  1. Fight fire aggressively, but provide for safety first.
  2. Initiate all actions based on current and expected fire behavior.
  3. Recognize current weather conditions and obtain forecasts.
  4. Ensure instructions are given and understood.
  5. Obtain current information on fire status.
  6. Remain in communication with crew members, your supervisor, and adjoining forces.
  7. Determine safety zones and escape routes.
  8. Establish lookouts in potentially hazardous situations.
  9. Retain control at all times.
  10. Stay alert, keep calm, think clearly, act decisively.

Eighteen watch-out situations

  1. Fire not scouted and sized up.
  2. In country not seen in daylight.
  3. Safety zones and escape routes not identified.
  4. Unfamiliar with weather and local factors influencing fire behavior.
  5. Uninformed on strategy, tactics, and hazards.
  6. Instructions and assignments not clear.
  7. No communications link with crewmembers/supervisors.
  8. Constructing line without safe anchor point.
  9. Building fireline downhill with fire below.
  10. Attempting frontal assault on fire.
  11. Unburned fuel between you and the fire.
  12. Cannot see main fire, not in contact with anyone who can.
  13. On a hillside where rolling material can ignite fuel below.
  14. Weather is getting hotter and drier.
  15. Wind increases or is changing direction.
  16. Getting frequent spot fires across the line.
  17. Terrain and fuels make escape to safety zone difficult.
  18. Taking a nap near the fireline. 

1949: Mann Gulch fire.  Thirteen died when the fire blew up due to strong winds.  From the time trouble was recognized until the men were dead was 11 minutes.  Those who died did so running uphill.  They died from asphyxiation or burns.  The fire was not affecting houses or civilian lives.  We had a culture from the 1910 fire, where 87 died, that all fires were to be put out before 10 a.m. the next day.  Ironically, this has created many problems we face today.

1994: South Canyon fire, near Glenwood Springs, Colorado.  In early July, a lightning strike started it.  Because some residents complained about smoke, a decision was made to fight the fire, which was not endangering any structures or lives, and was 5 acres when a decision was made to attack it, despite its being one of the lowest priority fires in Colorado at the time, where there were at least 35 fires burning, and resources were stretched.  When the fire was initially scouted, the difficulty and the risk were noted, and recommendations were made not to fight it in that particular area.  Catastrophes occur when there are major errors, but they also occur when there is a concatenation of smaller errors.  This fire was an example of the latter.  It was attacked because a person complained of the smoke–an inadequate reason.  Had the fire grown, it might well have been clearly inaccessible to attack in the place where the people who attacked it subsequently died.  It might have been fought differently.  I do wonder whether those who complained about the smoke ever wondered whether they were culpable.

Fourteen people died, including most of the Prineville, Oregon hotshot crew, when they descended a hill, in this worrisome area, in thick growth to build fire lines. Several members thought this maneuver was dangerous, because they had unburned fuel, extremely volatile fuel,  between them and a fire they couldn’t see (Watch out #9). Nobody spoke up, except some smokejumpers elsewhere on the fire, who did not think what they were asked to do was a good idea.  Eight of the ten major rules for fire fighters, 12 of 18 Watch Out guidelines were eventually compromised or violated.

A dry cold front came through that afternoon, predicted, but the information wasn’t relayed to the firefighters.  At 1520 hours, concerns were raised, and some left the area.  At 1600 hours, all left, but sawyers were still carrying their saws, and many were walking.  Twenty minutes later, they were dead, shelters not deployed.  Not only can fire move faster than we can run (this one moved 14 mph), superheated gases and radiant heat can kill people at a great distance, and winds can knock them over.  On Mann Gulch, winds lifted a survivor up and down three times.  The idea that fire suddenly erupts and people die with no warning is not true.  Fire does suddenly erupt, but usually there are hints.  There were such hints at South Canyon.  There were draws, and there was wind, an ideal situation for fire spread, and one that had been previously noted.  Many firefighters didn’t appreciate the severity of the situation until it was too late, for the safety zones were too far away and uphill.

The recommendations after South Canyon were hoped to make fire fighting safer.  They didn’t.

Thirty Mile Fire, Washington State, 2001.  Four fire fighters died after deploying their shelters in a rock field when a small fire earlier in the day suddenly exploded, overwhelming the crew. The problem was another concatenation of errors–virtually no sleep the night before (impairs judgment equivalent to being legally drunk), going suddenly to a fire that they hadn’t planned on, faulty equipment, slow start, and pulling in the lookout.  At the lunch spot, not a safety zone, two spot fires were noted up a dead end road (which had not been previously appreciated when the group arrived at the fire), and tankers were sent to the spots.  At this point, the video given by survivors stops, and the listener is told to put himself in the position of the fireboss, rather than knowing what happened later.  The fireboss sent more help to the spot fires, had no lookout to look at what the main fire was doing, and ultimately, the whole group was cut off from escaping from the lunch site the other way.  Instead, they went up the dead end road (which also had civilians present) to what appeared to be a safe area, with a stream to the east, a rock slide with no growth (but fuel between the rocks), and the road.

Thirty minutes before the fire overwhelmed the crew, many were taking pictures of themselves, not looking for safe spots or beginning shelter deployment, not knowing this would be the last picture of them alive.

Shelter deployment means that people were in an area they should not have been in.  They were too far from the safety zone.  That happens.  Shelters are a last ditch effort to save oneself.  Had everybody deployed on the road, they would likely all have survived.  But some deployed on the rocks.  They died of asphyxiation.  Many at the time were not adequately trained to deal with shelters, which one must be able to get in either standing or lying.  Several wore fusees and backpacks into the shelter; fusees burn at 375 degrees and can ignite if in contact with the shelter itself.  Some lost gloves, which were in retrospect available and nearby, and others left backpacks too close to the shelter, where they burned, adding fuel near the shelter.  I don’t know what I would do if I were in that situation.  I haven’t been trained; all of these people were.  Many deploying shelters do so when there is a great deal of wind from the fire, sometimes ripping the shelter from a person’s hand. When I saw this haunting video, I said to myself, “When the tanker on the downwind spot fire radioed that they needed additional help, that is when I would have pulled out.  Everything is going wrong on this day, and we need to regroup.”

We get back to the basic part of fire fighting.  It is dangerous, and everybody who fights fire knows that.  My experience is nearly nil, only having driven a water tanker on a controlled burn in 1995.  The culture had been not to question orders, and there is a degree of pride in being able to handle adversity.  Nobody likes to lose a fire, nobody wants to say that they couldn’t attack it.  Nobody wants to see houses destroyed.

What I don’t remember about 1994, although I could be wrong, was that we didn’t refer to the fallen firefighters as heroes.  They were professionals, and they were sadly victims. The fire should have been allowed to burn, nobody should have been deployed in any area that was unsafe, regardless of the risk to property and especially not because somebody complained about the smoke.  And that brings me to 19 years later, a lot closer to home.

2013:  Arizona.  Nineteen firefighters die fighting the Yarnell Hill fire.  The video on the Web site was quite syrupy, and I use that word exactly as I mean to. Nothing was mentioned about the “10 and 18”.  There was a discussion about the sudden, fast fire shift, which is a known phenomenon.   I read at least one hundred comments by others, many of whom are firefighters.  A lookout was posted, and he radioed that the winds had shifted and he was leaving.  What we don’t know is critical:  why did the Hotshots leave a safe area to hike downhill, into areas where they couldn’t see the fire, into areas almost impassable on a normal day?  We have heard remarkable things about the Superintendent, who put this group together in half the time of others crews.  Did anybody of the 18 others speak up about violation of the “10 and 18?”  Or was there a culture of expertise, like we have had in medicine and aviation, where nobody speaks up to a leader who is twice their age?

We heard that the fire was moving at unbelievable speeds of 12 mph.  It was moving faster at Storm King.  Winds were expected, but the way the winds shifted was not appreciated.  There were 2 minutes to cut a place and to deploy shelters, which meant that the fire was about 600 meters away before action was taken.  Were the firefighters not aware of how close it was?  At least 5 of the 10  and 10 of the 18 were violated.  Why?  We don’t know.  More than one report is comparing the Yarnell Hill fire with the South Canyon fire.  Both were initially small, both were in difficult terrain with extreme drought, and both were handled by hotshots.  Both had a major, predictable wind event, both had unburned fuel between the firefighters and the main fire, and both led to disasters.

This was NOT an Act of God.  That statement to me is a copout, an excuse for not trying to understand circumstances that people should understand, and a way to sweep the matter under a rug.  Mistakes were made.  Thunderstorm downdrafts, erratic winds, Venturi effects, plentiful dry fuel, and a hotter than usual fire are all understandable.  Whether we can predict what they will do is another matter, and evidence is beginning to mount that our modeling of fire behavior is inadequate due to increased size of fires because of suppression, climate change allowing bark beetles to survive winters, and more houses in the wildland-urban interface.  Ability to recognize danger and to speak up is part of firefighter training.  If we cannot adequately predict the worst case scenario, and plan for it, then we have no business sending people into harm’s way, except to save lives, not property.  Worst case scenario planning is why firefighters are required to have safety zones and exits to them, both hopefully plural.

Just as Challenger repeated 17 years later with Columbia, almost to the day, with many of the same cultural problems still persisting in NASA, so did South Canyon repeat 19 years later with Yarnell Hill, almost to the day.  I suspect, like NASA, there are still cultural problems in the firefighting community.  Hopefully, the investigation will uncover these issues, and the wildland firefighting community will address exactly how we will approach fires, what we will do, and what simply will not be tolerated.   We didn’t learn from Mann Gulch in 1949; 45 and 52  years later we had South Canyon and 30 Mile fires respectively.  We didn’t learn enough from them, and 12 years after 30 Mile we had Yarnell Hill.  My prediction:  it will recur.  My hope:  It won’t.

No more purple ribbons.

LOST

October 17, 2013

This is going to be easy, I thought.  I will drive to the base of a nearby mountain, climb 1.4 miles (2.2 km), 1000 (310 m) feet and come back down 1.4 miles.  I can do this in less than an hour, and I don’t need food or water.  It was afternoon; the Sun was in the southwest.

I arrived at the base, went up in 25 minutes to the summit, and came down another trail that had appeared on the Internet map to take a longer route, 2.4 (4 km) miles to where I had begun.  No problem.  I needed the exercise.  The trailhead where I started was west of me as I started down the trail.  All went well for 15 or 20 minutes, but then I noted by watching the Sun that I was heading south, and I needed to be heading north or at the very least northwest. I should have been walking with the Sun to my left, and it was to my right.

This concerned me a little, and right then I should have stopped and turned around.  The trail was wide and good, however, so I kept going.  When it bent towards the Sun and even a little beyond, I felt better, but I generally had the Sun on my right.  When I got towards the bottom, I saw a parking lot that was clearly different from the one I started at.  I saw a sign saying “west Trailhead 3.3 (5 km) miles.”  That was where I had started.  I was down the mountain but an hour’s walk from where I had started.

I saw a nearby road and thought that maybe the road would take me to the trailhead faster.  That was my second mistake.  I had no map of the road, and my Internet connection was not helpful, either.  But the road headed north.  That was where I wanted to go, until the road headed west and then southwest.  I thought more and more about turning around, and saw a woman walking.  I asked her if this road went near a certain landmark I had passed.

“I don’t know that place, but you’ve walked over the mountain and are on the back side.”

That is not what the Internet maps had shown.  I knew immediately what to do:  turn back. It’s a shame an hour earlier I didn’t do what I knew I needed to have done, for I would now be approaching where I wanted to be. When I reached the trailhead, I had two options:  completely retrace my steps, which was not a bad idea, but I would have to walk up to the summit again, 4.1 miles (6 km) in all, and why didn’t I bring water?  That way had a 100% probability of returning me to where I wanted to go.  Or, I could start on the signed trail that led north 3.3 miles.  The trail had a couple of forks that were not marked.  One led to the summit, which I considered, because that was familiar, but I stayed on the flat trail I had found–the Sun remained on my left, and within forty minutes was back at the car.

I was thirsty when I got back, and I thought what I had done is how people get into trouble.  Step 1, you have a sense of uncertainty., but you ignore it.  Step 2, you start fitting things into place so that you convince yourself you are going in the right direction.  Step 3, things aren’t right, and retracing your route seems too long.  Step 4, you try what turns out to be a shortcut, and it isn’t.  Step 5, you run out of daylight, you injure yourself, you panic, start burning energy and consuming water by running, get more lost, and you are stuck in the woods all night, with no food, water, or shelter.  I’m not young; my reserves are less, and while the young are often the ones who die of hypothermia, I am far from immune.

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

Seven years ago, on Isle Royale, I hiked in the dark after a wolf had visited my camp.  My flashlight was good, so I could see the trail, until there was a big blowdown in front of me.  I walked around the blowdown, and it took some time, but soon I was back on the trail.  Something nagged at me, however.  For whatever reason, I wondered if I had turned around. It happened to me once in broad daylight on the Appalachian Trail in 1998.  I stopped.  That was smart.  I took out a compass, which I had never used in the woods before, but always brought with me.  I needed to be going generally northeast, and my direction was southwest.  I had been turned around on the blowdown.  I thought I would come to it again, if I were correct, and I did just that.  I saw what I had done wrong and continued, northeast.  I listened to myself.

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

Twenty-one years ago, with nearly 90 days in the woods that summer behind me, I headed out on Burntside Lake for the Crab Lake portage several miles away.  I didn’t have a map for the particular part of Burntside I was on, but I had maps for the rest of the the lake.  My plan was to go due north and eventually reach the part of the lake that I had maps for.

About a mile from shore, I hadn’t arrived at the points listed on the map I had. I tried to “fit” some islands ahead of me into the map I had, and I kept going.  After a second and a third mile, the less certain I was whether I was on the map, or where the Crab Lake portage was.  I could still see the shore behind me, where I had launched.  I stopped paddling.

“You are lost,” I said aloud, to the waves.  “You have no idea where you are.  You don’t want to admit defeat and turn around, but do so.  Nothing good is going to happen if you try to keep going.”  I turned around, quite embarrassed, and two hours later was back in Ely.  The first place I went to was an outfitting store to see where I had been.

I never would have made the portage that night.  The next morning, I launched from a different point and had a good trip into the Burntside Unit of the Boundary Waters.  I didn’t get lost once, and I was comfortable the whole time.

Failure to prepare properly sets the stage for getting lost in the woods.  Take proper gear, even if it is a short hike.  I didn’t on the mountain.  A sprained ankle, a minor issue,  becomes a big issue on a remote trail. Check directions.  I had a compass, but the Sun was more than adequate.  If you can’t tell yourself, “I know where I am, how far it is to a certain point, and how I am going to get to the end,” you should be concerned.  Listen to your concerns.  Sure, it is fine to walk a few more minutes, but start considering turning around and going to the last point where you knew exactly where you are.  Don’t ever look for shortcuts through the woods.  Unless you have a clear line of sight to a distant trail, stay exactly on the trail you are on.

Don’t be afraid to tell yourself you are on the wrong trail.   Don’t be afraid to turn back to familiar surroundings.  Don’t be afraid of saying you don’t know exactly where you are. Don’t be afraid of later having people laugh at your getting lost or having taken the wrong trail.  Later being laughed at means later you are alive.

Be very afraid of being lost, in trouble, alone, and saying, “I can’t believe this is happening to me.”

CREAM PIES, BAD SERVICE, AND OCCASIONAL RECOVERY…WHAT’LL IT BE?

October 13, 2013

On the highway from Anchorage to Wrangell-St.Elias National Park, there is a small restaurant half way to the Richardson Highway, right near the view of the Matanuska Glacier.  If you are lucky enough to have the owner serve you lunch, you will have the choice of getting the dessert first.  I was at first taken aback, but the lady was an Alaskan, and I figured she knew what she was talking about.  Alaskans often do.

It was a fantastic lunch, with the best cream pie I ever had, followed by a grilled cheese sandwich.  On the way back from the Park to Anchorage, I had a late lunch, because I wasn’t going to eat anywhere else. I ordered the pie first and the grilled cheese second.  Granted, my lunch was not a big ticket item, but I was one customer who came back, because of how I was served.  I saw four national parks on that trip, and they were beautiful, as I expected they would be.  What I didn’t expect was to ever eat dessert first….and enjoy it.

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

“I’m sorry I didn’t get back to you.  I just got back from vacation, and I had a meeting that was dumped on me this morning.”

I heard that after I answered my phone to hear, “Mr. Smith, how are you?”

My answer was terse:  “That depends upon what you have to say.”

Normally, I don’t partake in pleasantries, which I have been trying to change for years.  In this instance, however, “How are you?” was ludicrous.  It ranks with a customer service person not helping you, and then ending the conversation with “Have a nice day.”  Do people realize what they are saying? The previous day, the same individual, from the cable company, had failed to show for an appointment to look at the wiring at my house and tell me what I needed to do to get service.  This was electrical science, not rocket science.

One hundred five minutes after the agreed upon appointment, a voicemail was left on my phone.  At the time, I had long since given up and did not have my phone with me.  Apparently, this individual didn’t have his phone either, at the time of the appointment, or he could have used it to call me earlier in the afternoon to cancel or to change the time, something in my era that required a land line and knowledge of where all the pay phones in one’s city were located.  I thought it ironic that a man from the communication industry couldn’t make a simple call.

We agreed to meet the next day at 1.  At 2, still waiting, I called him, with the above exchange.  He eventually appeared, told me about his vacation (to watch a football game) and eventually set up the service, although he didn’t stay around long enough to make sure it worked.  It didn’t, although I was eventually able to fix the problem myself.

Here are some lessons for people in the service industry:

  1. If you can’t keep an appointment, tell the customer immediately, apologize, don’t offer excuses, especially that you were on vacation (many people these days can’t afford them or are taking an unplanned, unpaid one), and had extra work.  Your family is interested in excuses; your customers are not.  We are interested in an apology and a new, early, convenient appointment.
  2. If you miss a second appointment, you are in trouble.  You begin the conversation with “I am so embarrassed, and if I can still convince you I will show up, I will give you a month’s of service free.”  That is an apology and use of a term called “recovery,” which was shown to me by the motel clerk in Anchorage, after I slept on the floor in the airport because they had given my reservation to another Michael Smith.  I got two nights in a large suite at half price.  Unfortunately, the night “sleeping” on the floor was not refundable.
  3. You are so in trouble, that you need to drop everything and serve that customer.  That means you don’t call ten minutes later and check where the customer lives, especially since you have a computer-phone which can give you that information as well as even substitute for a pay phone.
  4. You make it certain that you have your phone with you at all times, especially if you are in the–uhhh  communications industry, so if your boss calls you unexpectedly, you make sure that your customers are aware if there will be a delay.  If your boss objects to that, find a new line of work or a new boss.

I read body language well, and it was clear the cable guy either wanted to leave or needed to use my toilet. I’m not sure I ever did it right, but I have had doctors who were incredibly busy but made me feel they had all the time in the world for me.  Those people are worth a great deal.  Find them.

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

In this city, to which my wife and I travel frequently, we eat almost exclusively at a certain restaurant.  After a while, not only did they give us “a little extra” or “try this and see what you think,” great business practice, the owner, a woman, remembered us, despite our sometimes having been absent for months.  That is impressive; if you have that skill, you need to tell any potential employer you have it.  People like to be remembered.  Why would we eat anywhere else?

I was recently at this restaurant, this time alone.  Unfortunately, the owner was away on vacation, and there was a fill in staff.  The food was great, but the place wasn’t the same. I still left a large tip, because these days tips matter a great deal to people.

The next night, however, was different, maybe even a disaster.  As I entered, I noted many cars parked outside.  There was a large group in one room.  I sat down and immediately ordered, not because I knew there would be a wait, but because I knew what I wanted.  Fifteen minutes later, the woman across from me asked if anybody was going to serve her.  This was a bad sign.  Ten minutes later, I was told by one waitress there was a group of 14, and the kitchen was getting “slammed.”  There was an apology, but the lady still not had her order taken.

Fifteen minutes later, and fifteen minutes before I was going to leave, my food came, slid to me by the server, without one of the side dishes I particularly like.  I had to go up front to request that side dish, and when it arrived, it was again slid about a meter across the table to me by a hurried waiter.  Simultaneously, a table of 5 was getting special treatment by one server.  It was an elderly lady’s birthday, but I wished that they could have just ordered the dessert a little faster.  The lady across from me was now saying people who had come in behind her were getting served.  I finished as fast as I could and left.  I did leave a tip, less than I normally do, and left.

This restaurant was too busy that night.  The lady across from me will never go there again, UNLESS  there is recovery and her meal is free.  That would likely bring her back at least for another try.   Is a free meal worth it?  I think so.

The next night I returned.  Within 30 seconds of sitting down, I had my order taken and the side dish was at the table.  I had a good meal and left a good tip.  On the way out, I did talk to one server I knew.  I told her that had the restaurant told people there would be a 15 minute wait, they likely would not have had so much difficulty.  People are willing to wait to be seated, so long as the wait time is reasonable.  What people don’t like is be put at a table and forgotten.  Once a customer is seated, the process has to begin.  The server thought I had a good idea.  This isn’t even electrical science.

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

The following night, at a different restaurant, I got prompt service, but the menu was  stained with food, and I received an “is everything OK?” called to me from about 10 meters.  To be fair, I was the only one in the restaurant, so maybe that was fine.  It seemed a little tacky, however.  The bill came with a feature that costs the restaurant industry millions in lost revenue every year:  Nobody asked me, “Would you be interested in looking at our dessert menu?  We have some interesting choices.”  I’m thin for my age, and on this particular day, I was hungry.  I paid the bill, left a better tip than deserved, and left.

You can bet the lady running the restaurant in the Alaskan hinterland wouldn’t have forgotten the dessert.

IMG_1526

DR. NONEG

October 11, 2013

When I was medical director of a hospital, I dealt with a Dr. Noneg, a prominent member of the medical staff.  Noneg entered practice near the time as I was changing my role to hospital medical director from neurologist.  Because of personality clashes, he soon left the practice that hired him.  He wouldn’t budge on his demands, but he was new to the practice, so there were choices, but not very good ones.  He could lessen his demands, or he could leave.  He left and began his own practice.  He was against insurance companies, as many were, and for some time got a great deal of press because of his outspokenness.

Noneg occasionally practiced outside his field.  When we were both in practice, he handled carotid artery disease cases, something I believed then and now only a neurologist should do.  Since 1984, I had tracked outcomes and referred my patients to only one surgeon, whose outcomes were slightly better than untreated disease.  I made my data available, but the local surgical community slammed me for my data and approach.  I was the only one to deal with this issue using outcomes at my local hospital.  Dr. Noneg did not.  He handled MS cases, which an internist can, but really a neurologist should.  For me, it was a matter of doing what is best for the patient; I wasn’t protecting my turf. Indeed, I wanted less work, not more.

Noneg and I clashed when it came to coverage of the emergency department at night.  Many patients who come to the emergency department don’t have physicians.  If it were a particular specialty, that patient would be assigned to the physician on call for that speciality.  Each physician was on call in a rotation that lasted a month, and several of us had several months a year we had to take new patients.  When one was building a practice, this was a way to do it, unless, of course, the patient couldn’t pay for the services.  I wrote off $30,000 a year in unpaid bills for over a decade.  It was considered normal, but I made good money in spite of it.

Noneg didn’t like this coverage arrangement, and he convinced many of his colleagues that the hospital should pay for such, $500 a night per specialty.  Needless to say, this would have been a great expense for the hospital, since there were at least ten specialties a night that would need payment.  Noneg wouldn’t negotiate.  Not a bit.  In many ways, he reminded me of the Republican Party.  There was no give or take.  If you did what he wanted, he was a nice guy.  If you didn’t, he was an enemy.  Had the hospital capitulated, I certainly would have been laid off, which I could have dealt with, but then the physicians would have had to deal with their issues (yelling at nurses, turf wars) themselves, which physicians, for all their power, are loath to do.  By the way, physician behavioral issues were the single biggest problem I faced as medical director.  I counted.  “Administration is the problem,” was said, until there was a thorny issue, and then “administration needs to fix it.”  Substitute “government” for administration, and you have a common national refrain.   We hate government, until a Cat 5 or an EF4 devastates our town, and then we can’t have enough of it.

Back then, we had nurses from managed care companies review patient charts to see if continued care was necessary in the hospital.  On the one hand, it was a physician’s decision whether or not to discharge a patient, not an insurance company’s.  On the other hand, many physicians would write “Doing well” for days, without any indication of why if the patient were doing so well why they needed hospitalization.  Hospital resources were consumed, not the physician’s worry.  But if somebody is paying the bills, that somebody usually wants to have some control over the costs involved.

An additional issue with utilization occurred in winter, because the city had an influx of visitors, and hospital beds were in short supply.  Getting patients discharged was necessary to allow new admissions, otherwise having to go on “divert,” which was not good for the city.  It was not uncommon for patients to stay in the Emergency Department 24 hours, no bed being available.  This was not good care.  When we didn’t have a bed, because a physician hadn’t visited that day, the physician said the patient wasn’t ready to go, without any documentation in the chart, or because the person covering for a physician refused to make a decision, we had one less bed we could fill.  Dr. Noneg responded to the notes from managed care nurses, polite as they were, with a simple “Drop Dead.”

In a hospital, that is not particularly funny.  Nor was it helpful.

Dr. Noneg persuaded his colleagues that the care of emergency department patients was the hospital’s problem, and the physicians stopped accepting them.  Accordingly, the hospital hired people willing to practice in the hospital full-time, called hospitalists.  They took care of these patients, and during their stay, found a physician willing to care for them after discharge.  I would have liked that job: regular hours, taking care of sick patients, then not having to manage their problems in the office afterwards.

Soon, hospitalists started caring for more and more inpatients.  For some physicians, who were very busy in their office, this was a good idea.  For others, who found that they were no longer going to be able to take care of their patients in the hospital, this was resisted.  The state medical association tried to intervene, but when physicians give up control of taking care of emergency patients, sometimes there are consequences.

Not negotiating has consequences outside of medicine.  It has tied Congress in knots over a host of issues, all of which could be dealt with given some creative thinking and a little willingness to let the other side have something.  But if you are Dr. Noneg, or a member of the Tea Party, you simply don’t negotiate.  Maybe the other guy caves, maybe not.  I learned early in life that the world isn’t going to do what I demand it do.  I had a lot of temper tantrums.  Some apparently do not learn that.

Eventually, Dr. Noneg set up a boutique practice, where he would be available 24/7 for his patients, each of whom paid him $1500 a year.  It wasn’t for the money that Dr. No did this, of course, except whenever somebody says it isn’t for the money, it is always for the money.  Dr. Noneg tried to have his patients jump the queue in Emergency Departments, but one soon learns in medicine that ED physicians and nurses are extremely strong-willed individuals who work in a high stress environment and deal with it well.  They don’t negotiate, either.  Dr. Noneg lost, and his patients had to wait.  The $1500 didn’t cover hospital or consultant costs, although I suspect–but cannot prove–many patients thought it would.

A while back, I got a call at home from Noneg’s office, wanting “my staff” to pull a chart of a patient I had once treated.  I haven’t practiced in over 20 years, and my charts, if still intact, would have remained with my group.  I was surprised that Noneg didn’t know that.

I was also surprised he didn’t demand I produce the charts. That would have been an interesting negotiation.  I would have enjoyed it.  But the world doesn’t always work the way I want it to.