Is There a Doctor in the Kitchen?

     Anyone who reads my blog knows that I don't hesitate to moan and groan about the high cost of health care and medical insurance. In my defense, part of the reason is that, as an early retiree, I'm part of a minority of Americans who pay the full cost of their own medical insurance. I'm not among the majority of public workers, corporate employees and Medicare-covered seniors who typically pay only 10 - 20% of the real cost.

     The other reason (according to my kids, at least) is that I'm cheap.

     But part of the reason I'm cheap is because, for the past ten years, ever since I was forced into early retirement, that monthly health-insurance bill has eaten up a big chunk my income (along with college tuition, but that's a whole other issue).

     So I ran across an interesting article in last week's New Yorker, "Big Med" by Atul Gawande, that makes an interesting case for how we might control medical costs and improve results as well. Dr. Gawande is a surgeon at Brigham and Women's Hospital in Boston, a professor of surgery at Harvard Medical School, and a staff writer for The New Yorker.

     One Saturday the doctor dines at the Cheesecake Factory, and he wonders why a medical facility can't operate more like a chain restaurant -- one that serves 80 million people a year with over 300 menu items, and where most dishes are made from scratch and the waiters are efficient and friendly.

     Restaurants have been able to bring the efficiencies of chain production to the complicated business of serving sit-down meals, but medicine still operates like a collection of "mom and pop" stores. Unlike the Cheesecake Factory, medicine has been "unable to deliver a range of services to millions of people at a reasonable cost and with a consistent level of quality."

    Chain restaurants have an advantage over small independents because they are big enough to enjoy buying power, they can centralize common functions, and they adopt innovations faster than a random group of individual restaurants.

     Doctors have historically worked for themselves or as part of small groups. Hospitals were community based. Doctors have traditionally billed patients for services rendered, and they therefore have had various incentives to order more, unnecessary tests and procedures, to pad their bills, practice defensive medicine or to satisfy nervous test-seeking patients.

     But in the last decade, Gawande notes, more and more doctors have begun to join larger medical groups or else sign on as employees of hospitals that are merging into larger hospital chains. Hospitals are beginning to benefit from economies of scale, and they increasingly sign contracts with Medicare and the insurance companies to be paid not on the number of procedures performed, but on the basis of how well they meet certain cost-reduction and quality-improvement targets.

     What especially struck Gawande about the Cheesecake Factory was that there are precise instructions that cover the ingredients of all the menu items and their presentation. But each cook has considerable leeway about how to turn the ingredients into the final product. Plus, each restaurant has a kitchen manager who checks the final product, making sure that standards are being met. Managers are respectful of a cook's skills and experience, but oversight is fairly tight. There are guidelines for how many employees a restaurant should have, based on the number of customers, as well as strict measures of how much waste can be tolerated. The company target is 97.5% efficiency -- in other words, they throw away only 2.5% of the food they purchase. (Think about your own kitchen, and how much of the food you bring home form the grocery store gets thrown out.)

     A common complaint among medical patients is that they are shuffled from specialist to specialist, with no one person taking overall responsibility for their care. Gawande says that hospitals would benefit from "kitchen managers" who are responsible for getting clinicians to agree on precise standards of care, making sure that they follow through on them, and ensuring that the final results maintain the agreed-upon standards.

     Gawande notes, for example, that there is no standard practice for knee surgery. Even within the same hospital, different doctors use different makes of artificial knees; they use different procedures, different protocols for anesthesia, different strategies for post-operative pain management and physical therapy. There is no organized effort to identify the best products and procedures, then figure out how to standardize them and disseminate them to a broad range of medical practitioners.

     There should be one best standard way to do knee replacements -- or any other medical procedure -- a method that everyone follows. Beyond that, he argues, customization should be 5% of what the doctors do, not 95% of what they do.

     In medicine, new procedures have traditionally taken a long time to trickle down to the majority of patients. He cites the example of beta-blockers, used after a heart attack. It took some 15 years between the time the studies confirmed the benefit, and the time the majority of Americans were offered the new treatment.

     But the Cheesecake Factory puts out a new menu every six months. It takes them only seven weeks to roll out the new menu, including finalizing recipes, purchasing and distributing the new ingredients, changing the menus and training the staff.

    Gawande admits there is no guarantee that increased size and tighter controls will improve medicine and bring down costs. Sometimes bigger institutions lead to monopolies that raise prices, stifle innovation and benefit owners rather than customers. But he feels that larger, more uniform medical organizations, following standardized rules and regulations, with some government oversight as well as transparent methods that are open to public scrutiny, could provide better, more consistent care for everyone, at lower cost. Just like the Cheesecake Factory.

     If you don't want to read the full, lengthy New Yorker article cited above, try this npr interview with the doctor from last week.

     As for me, I've never been to a Cheesecake Factory. I googled it. There's one a little over 20 miles from my house. Dr. Gawande makes it sound good -- I'll have to go try it out.

       

     

The Strongest Force on Earth

     You might think the strongest force on Earth is a hurricane or a tornado or an earthquake. But you'd be wrong.

     So what do you think it is?

     I'll reveal the answer in a minute. But to explain, I first have to tell you the story of my leaf blower.

     I acquired a leaf blower about 20 years ago -- a handheld blower, not the heavy duty kind you push like a lawnmower. At the time I lived in a four-bedroom house with a big lawn to take care of, in a fairly upscale neighborhood. But perhaps we were living above our station, because unlike most of the people on our street, we couldn't afford a lawn service, so I took care of the yard myself. Once my son got to sixth grade he started cutting the grass, although not without a bribe . . . I mean, an increase in his allowance. I also got my son, along with my wife and daughter, to help rake leaves in the fall. But to be frank, they were neither enthusiastic nor effective.

My new leaf blower

     So anyway, I bought a gas-powered, handheld blower to help me with the leaves. It also proved helpful in cleaning off the patio and blowing out the garage. I even used it to clear off snow if the storm wasn't too bad and the snow wasn't too wet.

     After my wife and I got divorced I moved to a condo. And I brought my gas-powered blower with me. I no longer had leaves to get rid of, but I still had a garage that got dirty, a deck that needed clearing off, and a short walkway that got dusted with snow.

     When I moved in with B, she had two boys who mowed the lawn and did yard work. But B's theory was that you couldn't get a male to do any work around the house unless he had a toy to play with, preferably something that made a lot of noise. She had a riding mower, which the boys enjoyed driving around the yard pretending to be race car drivers when they were really cutting the grass. She had a weedwacker, an electric hedge clipper, and even a gas-powered edging tool. What she didn't have was a blower.

     So now she not only had me, but she had a blower as well.

     The problem is that my 20-year-old blower gave up the ghost a few weeks ago, when I was tasked with cleaning off the deck in preparation for some guests coming over for a cookout. You know what B made me do?!? Sweep the deck. By hand. With a hand-powered broom. I couldn't believe it -- that's technology from the 14th century!

     But, being a gentleman, I did the job with aplomb . . . and without complaint. (No, you may not speak to B to verify this statement.)

     So anyway, this morning I was sitting comfortably on the TV room couch, drinking my coffee, reading a magazine and getting ready to watch the Olympics. There was some handball, field hockey kind of thing, pitting the Ukrainians against the Netherlands (I think). You know, must-see TV. So B steps into the doorway, dressed for work, looks me up and down and says, "Are you by any chance thinking of getting another leaf blower? Or were you just thinking we could coast along without one?"

    "Why, thank you for the compliment," I smiled, "by assuming that I was doing any thinking at all."

     She gave a polite little laugh to show she was being patient, then continued looking at me.

     "I guess, now that you mention it," I went on, "a blower could come in handy. But do we really want to invest in new equipment when, you know, we're not going to be here too much longer?"

     (We're thinking of moving, so we're hesitant to start buying new stuff for the house -- well, actually, I'm the one who hesitant about buying new stuff, even though there's no way we're moving for at least five years.)

      "Well, that's what I kind of want to know," she said. "Because there's debris all over the driveway. And I figure if you're going to buy a new blower, you could blow it off. But if you're not, then I'm wondering if it's up to me to sweep it off."

     "Oh, I see," I responded slowly. "Gee, I could have asked for a blower for my birthday." I paused and looked down. "But my birthday is over."

     "Yeah, you'd have to go buy one yourself."

     "On the other hand, your birthday is coming up," I ventured. "Would you like a leaf blower for your birthday?"

     "You're not getting me a leaf blower for my birthday."

     "But you just said you were going to have to sweep the driveway," I explained patiently. "If I got you a leaf blower, it would save you a lot of work. To me that sounds like a pretty good birthday present."

     "Very funny," she retorted, although it seemed as if she didn't really appreciate my dry, sophisticated humor.

     "Well, maybe I should buy one for myself," I finally allowed. She nodded agreement and said goodbye and went off to work.

     The long and short of it is, I hightailed it down to Sears later in the day and bought myself a leaf blower. An electric one this time. On sale for $69. I brought it home, anxious to try it out. I assembled the machine, got out the extension cord, and started by blowing off the deck, then the front walk, and then I did the garage. Actually, it was kind of fun, and it was plenty noisy.

     Which brings me back to the strongest force on Earth. I blew the dust and dirt and leaves out of the garage, no problem. But no matter how much I blew at those cobwebs and spiderwebs, they did not budge. They swayed and bent under the force of the air coming out of the blower at 250 m.p.h. (or, so it was advertised), but they did not break. I knocked a few down with the end of the blower -- but even then they didn't really blow away, they just stuck to the wall.

     And so, you're thinking, finally the answer:  It's the spiderweb that's the strongest thing in the world.

     But that's not true, either. The spiderweb is the third strongest thing in the world. What's the strongest? That, you can decide for yourself. Is it the inertia of the male lying on the couch, drinking his coffee and watching TV? Or is it the female force, levering the husband off the couch to perform a routine household chore?

     I think you know the answer.

The Men Are Gone

     At first I thought it was just me. I lost my job at age 53, never to find full-time employment again. Now ten years later, I find myself sitting at home, working around the house, playing golf with my friends and picking up a few freelance assignments which I can do from my computer -- while my better half goes off to her full-time job every day.

     B works at the library. I called her the other day and a man answered the phone. I thought I had the wrong number, because the library is staffed entirely by women. One man worked at the library a few years ago, but they ran him out because he didn't get along well with his fellow staff members.

     But no, it was the right number. The library director, a woman, had hired a temp to fill in for the day. Meanwhile, the president of the library board of trustees is a woman. The board consists of seven women and three men.

     In our town, the town supervisor is a woman. The president of the board of education is a woman. The PTA is run completely by women -- although the men still dominate the volunteer fire department.

     I look around at my friends. One lost his job in his 40s. He tried to start his own business, then had some health problems, and now in his 50s he's being supported by his wife who commutes to the city every day. Another friend is a writer. He sits at home while his wife goes off to work. My friend Joe was forced into early retirement a few years ago, when he was 58. His wife went back to work after their kids had grown. Now he's the house husband; and she's the bread winner.

     According to the Bureau of Labor Statistics, since 1970 the female participation rate in the workforce has increased from 43% to almost 60%, while the male participation rate has gone down, from 80% to 71%.  

     Does it sound like I'm complaining? I don't mean to. I'm happy sitting at home, piddling away my time, picking up a few jobs here and there. After all, I punched the time clock for 30 years. That's enough for me.

     But the issue came up again this morning. B is helping to run the charity auction at her church. She's looking for an auctioneer. "For some reason I think a man would be better," she mused. "But there aren't too many men at my church." Then she paused. "And the men who do go to church aren't very charismatic, that's for sure."

     "What about the elders?" I asked, "Isn't there an elder who could do the job?" I was thinking there must be at least one self-confident man, used to public speaking, among the group that runs the church, a man who would feel comfortable hosting an auction, serving as master of ceremonies.

     She paused for a moment, and I could see her thinking. "Actually, there aren't many men who are elders, either." She counted them up -- ten of the elders are women, only four are men. "Gee, it used to be all men. Now there are hardly any." She gave me a significant look and asked, "Where are all the men?"

     I didn't have an answer for her, but it reminded me of the time I first took my daughter to veterinary school, a few years ago. In the big hallway of the main building hung a row of photos of graduating classes, going back to the 1950s. Those old black-and-white photos showed graduating classes that consisted exclusively of men. One photo after another marched down the hall, showing well-dressed, clean-cut men graduating from veterinary school. Then, sometime in the 1970s, a few women began dotting the pictorial landscape. By 1990 the classes were half men, half women. And in more recent photos, the graduating classes are overwhelmed with women -- my daughter's class was more than three-quarters women, barely 20% men.

  
     Today, more women than men go to college. Some 58% of undergraduate students are women, even though there are more college-age men than women in American today. According to the Bureau of Labor Statistics, for 2011 high-school graduates, the college enrollment rate was 72.3% for young women and 64.6% for young men. (Interestingly, in higher income groups, men and women go to college in roughly equal numbers; it's among lower-middle-class and poor families where women go to college in much larger numbers.)

     One Minnesota college admissions officer noted ruefully that the admissions pool had recently fallen to just 30% male. In the past year it had increased to 34% because, he admitted, "We actually did a little affirmative action."
    
     Meanwhile, in 2009, for the first time, more women than men earned doctoral degrees -- 28,962 women to 28,469 men. But hold on. Men still do "win out" in one statistic. The female high-school dropout rate is only 7%. The male dropout rate stands at a little over 9%.

     Don't ask me what's going on. I'm just sitting here, happily retired. But something is going on.

Remember Her?

     She was born in Port Arthur, Texas, in January 1943. Her mother worked as a registrar for a local business college; her father was an engineer for the oil company Texaco. Can you figure out who she was?

     She sang in her church choir, but as a preteen spent more time perfecting her painting skills than practicing her scales. She went to her local public high school where there must have been something in the water. One of her classmates was actor G. W. Bailey (Rizzo in the TV series "MASH", currently Detective Louie Provenza in "The Closer") as well as football player Jimmy Johnson (who played for the national championship team at University of Arkansas and later coached the University of Miami to a national championship and the Dallas Cowboys to two Superbowl championships.)

     However, she was not a standout in high school -- at least not for the right reasons. She gained weight and suffered from a bad case of acne, and instead of listening to current pop music, she fell in with a crowd that listened to African-American Blues singers like Bessie Smith and Billie Holiday. She was taunted with nicknames like "Pig" or "Freak" or "Creep." Later, looking back, she simply described herself as a "misfit."

     She went to Lamar State College in Beaumont, Texas, then to the University of Texas, where she recorded her first song, "What Good Can Drinkin' Do." A 1962 article in the Daily Texan called "She Dares to Be Different" began: "She goes barefooted when she feels like it, wears Levi's to class because they're more comfortable and carries her autoharp with her everywhere she goes so that in case she gets the urge to break into song it will be handy."

Her psychedelically painted Porsche

     She left college in 1963 and headed to San Francisco, where she teamed up with fellow up-and-coming musicians to record some blues standards. In San Francisco she also launched herself into the drug scene, taking amphetamines and psychedelic drugs, washing them down with Southern Comfort.

     In 1965 she tried to clean up her act. She returned to Port Arthur, Texas, and went back to school at Lamar College, while occasionally making the trip up to Austin to perform solo, accompanying herself on the guitar.

     The following year a music producer from San Francisco recruited her to join a band, and so she moved back to California and began to play at the Avalon Ballroom and other venues. The band released its debut album in August 1967, which included the hit single "Down on Me." They toured the East Coast where they appeared on the "Dick Cavett Show" and performed with Jimi Hendrix, Joni Mitchell and Richie Havens. Time magazine called the lead singer "probably the most powerful singer to emerge from the white rock movement."

     The band, called Big Brother and the Holding Company, put out a second album, Cheap Thrills, which was almost immediately certified gold and reached Number 1 on the Billboard charts. It featured the hit single "Piece of My Heart" and a version of the George Gershwin song, "Summertime," the kind of soulful rendition that could only have been performed by . . . Janis Joplin.

     When Janis Joplin first joined Big Brother, after returning to San Francisco from Texas, the band resolved not to take drugs. The resolution was well-intended, but soon was diluted by alcohol and eventually by the harder stuff. By the time Janis Joplin appeared at Woodstock in August 1968, she was injecting drugs intravenously.

     Joplin broke with Big Brother at the end of 1968 and formed a new group, The Kosmic Blues Band, which lasted a year and recorded one album. Joplin then started the Full Tilt Boogie Band, which she took on tour across Canada, ending in Boston, playing her last live performance at Harvard Stadium on August 12, 1970.

     At the end of August she checked into the Landmark Motor Hotel in Los Angeles and began rehearsing and recording a new album. The last recording she completed, on October 1, 1970, was the a cappella "Mercedes Benz", in which she asks the Lord to buy her a Mercedes Benz.

    Three days later Joplin's producer grew concerned when she didn't show up for rehearsal. He sent the band's road manager to the Landmark to see if anything was wrong. The manager spied her psychedelically painted Porsche sitting in the parking lot, and when he got up to her room he found her lying dead on the floor beside her bed. The official cause of death was overdose of heroin, possibly combined with the effects of alcohol.

     Janis Joplin was cremated, her ashes spread over the Pacific Ocean from an airplane. Her last album, Pearl, came out posthumously in January 1971.

     She died at age 27, but her legacy lives on -- in her style, in opening new opportunities for women in rock music, and in influencing later popular singers. Current female vocalist Florence Welch, of Florence and the Machine is one who, along with Stevie Nicks, Nina Simone, Bette Midler and others, acknowledges her debt to Joplin. Said Welch of Joplin: "There was always a sense of longing, of searching for something. She really sums up the idea that soul is about putting your pain into something beautiful."

     Tony Award winner Nina Arianda is scheduled to play Janis Joplin in a biopic film directed by Sean Durkin, scheduled to begin production early next year. 

     But here is the original Janis Joplin, with that soulful song appropriate for the season:

Is Anyone Watching the Olympics?

     Picture this. We had some relatives over for a late lunch last Sunday. So B's two sons came by the house. Afterwards, the guests left, and after clearing the table her two sons drifted into the TV room. I stepped up to the kitchen sink, like I usually do, and wrestled with the dirty dishes, while B scurried around straightening up, putting leftovers away, drying special dishes that don't go in the dishwasher.

Missy Franklin now has two gold medals

     I finished the dishes and went into our TV room, where the boys were watching the Olympics. I sat down, and found myself drawn into this one particular match.

     A few minutes later B came in and sat down. She watched for a minute or two, then lost interest. She reached over to the coffee table, picked up the newspaper and started reading through the arts section.

     Some time later -- one minute? ten minutes? I don't know, time stood still as I watched the ball being batted back and forth over a net -- I looked up from the TV. B's older son was sprawled across a chair, eyes glued to the screen. B's younger son, ignoring the iPad on his lap, stared at the TV with his entire face glazed in wide-eyed wonderment. B's head was still buried in the paper.

Two British beach volleyball players, in uniform

     Can you guess what event we were watching? Women's beach volleyball.

     But aside from what I thought was this humorous insight into human behavior, the Olympics in our household have been rather unremarkable. And I've noticed that there are almost no blog entries among our crowd of retirees involving the Olympics (besides this one from Gabbygeezer). So I wonder if people are watching.

     B and I missed the opening ceremonies. But I heard a report saying the TV audience was larger this year than it was for the Bejing Olympics in 2008. B's younger son went to an Olympic party with his friends that first night to watch the event, and he reported back: "It was cool, especially when they lit the torch."

Ryan Lochte, challenger to Michael Phelps

     So I must admit our viewing of the Olympics has been somewhat sporatic. I watched a few minutes of a bicycle race but got tired of staring at the cyclists' butts, which is all they seemed to show. I have seen a little bit of the women's gymnastics. I like Gabby Douglas from Virginia; she's cute. But even though the team won the gold medal, there didn't seem to be any surprises -- and no breakout stars.

     I like swimming and diving. Michael Phelps and Ryan Lochte have done pretty well, but not spectacularly. Colorado's Missy Franklin was fun to watch. I saw the synchronized diving (I have an interest in diving because my daughter was a diver in high school and college) and I enjoyed the show. Synchronized diving seems a bit contrived; but it is amazing to watch. The Chinese dominate all the diving events, but the Americans have done well so far, winning a few medals. I especially look forward to seeing women's springboard (scheduled for this coming Friday, Saturday and Sunday) because my daughter knows American hopeful Cassidy Krug from Pittsburgh. I met her once; she's a long shot, but we're all rooting for her.

Cassidy Krug will compete in springboard diving

     I also saw a bit of ping pong. Again, the Chinese dominate. We have a ping pong table in our basement, and the boys and I can get pretty serious about it. I beat B's older son most of the time; her younger son some of the time; and I lose to my own son almost all the time. But even though we're amateurs, and play kind of a different game, I really do appreciate just how good these Olympians are.

     For us, the Olympics is just a show on TV, with an occasional controversy. But when you think about it; when you consider the talent and hard work and total dedication to their sport that these people commit to, and how fast and strong and skilled they all are, it's absolutely amazing. And it's (ahem) a great place to see the human body in its most perfect form.

     There's still plenty more Olympics ahead of us. Is anybody watching?