Mystery Photo 25b: What is the name of the River on which this city lies?

     Here is a photo of  sunrise over the Holy river on which Mystery Photo 25 is located. Can you name the river? You have probably by now guessed that the country is India.

Mystery Photo #25a: Name the city!

      This is the first time I will offer a two part Mystery Photo question? It may be quite easy to identify the country in which this photo was taken. There are a few choices, but I suspect you will all guess correctly on the country. Secondly can you guess what this holy river is called? And finally, if you get this far, what is the name of the city? In Mystery Photo #25b, I will ask another question about this location based on some different photos. Hint: Dig deeply into your knowledge of the Rigveda and prosper in this life and the next.

     I wish you some educated guessing on this one!

"Knight, knave, or pawn? Which is your doctor?"

     I am trying to go through some of my stacks of saved tear sheets. This was always a habit of mine -- to tear out sheets from medical journals, articles, the AMA newspaper and even lay print sources and stack them up somewhere to read later. Unfortunately time would often interfere with this "Read later" intention. And even as a retired physician, lack of time still interferes. So these stacks of paper reside in various places in my home. We are fortunate to have a big home and so these stacks can accumulate for some time. However, finally even in our large home, they begin to impinge upon my positive attitude and begin to weigh on me. Then I must develop a mood in which I can ruthlessly go through them and throw away a huge percentage. It was during such a purge that I came upon this article from JAMA, September 1, 2010 -- Vol 304, No 9.This was a commentary by Sachin H. Jain, MD, MBA, and Christine K. Cassel, MD entitled "Societal Perception of Physicians:  Knights, Knaves, or Pawns? "  Both authors are affiliated with the Office of the National Coordinator for Health Information Technology, Washington, DC. There are many writings in our medical journals that I think should be more available to the general lay public. This article is just such an article. I recommend that all past, present or future medical patients -- that basically means everyone -- read this with concentration. It is short but very well written.

 http://jama.jamanetwork.com/article.aspx?articleid=186487

The above site gives you the first page of this article but will only let you see the second page if you sign up to JAMA (Journal of the American Medical Association). Therefore I have provided the second page below:

     "Implications
     "Le Grand's work on post-World War II British social policy found that perceptions of human motivations gradually transformed, with the prevailing view of the typical British citizen morphing from knight into knave as the costs of maintaining an expensive welfare state increased.
     "US perspectives on physicians have undergone a similar transformation with the increasing cost (both to taxpayers and to individual patients) of health care delivery. As physician behavior has been tied to these rising costs and increasing scrutiny has been applied to the quality of care delivered, policy discourse often reflects the perspective that physicians are an obstacle not an enabler to a functioning health care system. Rather than being counted on to exercise their professional ethic to address problems in health care delivery, physicians should be guided to do what is right with an increasing menu of incentive payments (ie, pay for performance or value-based purchasing) or strict regulations. Rather than being counted on to maintain their knowledge and expertise on their own accord, they are subject to periodic examinations to demonstrate continued proficiency.
    "These views are grounded in evidence of unwarranted variation in care, clear evidence of waste and even fraud, and decline in knowledge over time.The modern US physician is regarded as either a knave or a pawn and is seldom regarded as a knight. but the evidence that has led to distrust of physicians does not apply universally and many physicians still are the knights in the health care system. How can society be sure not to undermine those motivated by professionalism while guarding against those motivated by self-interest?
     "Not all policy prescriptions have abandoned the view of physician as knight. Prepaid models of health care payment such as accountable care organizations and the patient-centered medical home place responsibility in the hands of physicians -- with the idea that physicians will be responsible stewards. In these examples, physicians must be counted on to organize and structure care delivery, responsibly use resources, and measure and improve individual and population outcomes. Still, it is perhaps the knavish conception of physicians that makes these physician-driven models of health care delivery more the fodder of pilot projects and demonstrations than models that are rapidly adopted and widely disseminated.
     "Le Grand offers an important lesson and warning: it is critically important to understand and get 'true motivations' right. Disaster may follow if persons largely of a knavish quality are treated as knights; but the same maybe true for 'policies fashioned on a belief that people are knaves if the consequence is to suppress their natural altruistic impulses and hence destroy part of their motivation to provide a quality public service.' Le Grand further warns that policies that 'treat people as pawns, may lead to demotivated workers...again causing adverse outcomes for the polices concerned; while polices that give too much power...may result in individuals making mistakes that damage their own or others' welfare.
     "The US public would be wise to heed Le Grand's advice and carefully consider whether its perceptions of physicians match reality. For their part, physicians must thoughtfully consider whether and how they contribute to the perception that they are knights, knaves, or pawns."

References:
 Le Grand J.  Motivation, Agency, and Public Policy: Of Knights, Knaves, Pawns and Queens, New York, NY; Oxford University Press, 2003.

Choudhry NK, Fletcher RH, Soumeral SB. Systematic review: the relationship between clinical experience and quality of health care.  Ann Intern Med. 2005; 142(4) 260-273

Committee on Quality and Health Care in American; Institute of Medicine. Crossing the Quality Chasm. Washington DC: National Academies Press 2001.

McClellan M, McKethan AN, Lewis, JL, Roski J, Fisher ES.  A national strategy to put accountable care into practice.  Health Aff (Millwood). 2010; 29(5) 982-990.

Enthoven AC, Tollen LA.  Toward a 21st Century Health System: The Contributions and Promise of Prepaid Group Practice. San Franciso, CA; Jossy-Bass; 2004.

     Naturally, reading this led me to consider my own career which is now in the past, but which spanned a time period notorious for rapid and dramatic healthcare system changes. I know from my own experience that remaining a "knight" in the current healthcare system, though obviously desirable and expected by most patients, is exceedingly difficult. It involves expenditure of precious time during and after the patient visit and as a result since the main thing that primary care physicians have to sell is their time, being a "knight" reduces the physicians pay. Still many physicians are willing and do accomplish this exacting task. I like to think that I did at least some of the time. As an example, as was often shown in studies, being a woman physician, I spent, on the average, more time with my patients, and therefore saw fewer patients in a day. But I must admit that sometimes the battle that was required against insurers, and other providers as well as sometimes against the patient's own views themselves, often became overwhelming. When that would happen, I would not uncommonly resort to the "pawn" role. Sometimes it was just easier to say: "I'm sorry, but your insurance doesn't cover that test." During my years of practice, the amount of regulations, the interference of insurers and most recently the governmental requirements and guidelines became more and more obstructive to the "knight's" role. I think that is why many physicians volunteer in other countries or on the Hope Healthcare ship, and in other such opportunities. There they can totally fulfill the "knight" role. It is certainly a refreshing role to fill and a goal that all we MDs had when we graduated from medical school.

     I must make a comment about the "knave" role. I know that such physicians exist. They are the "in and out" physicians who hurry patients through their system, increasing the bottom line by volume, and decreasing the time that the MDS themselves spend with direct patient care. They may indeed learn a new procedure and perform it with excess in order to pad their bottom line. But I do think these physicians are rare. Even the super specialist feels a need to relate closely with the patient. Our selection for medical school and the education and breeding that goes into those 4 years of training holds too strong a power for most MDs to become outright "knaves." Indeed, the question is how to weed out or at least identify those few "knaves" without making the regulations so intense that it turns all of the "knights" to "pawns," and maybe even eventually into more of a "knave." This weighty question is very difficult to answer. But I fear that we have tipped too far into these regulations and requirements. Many physicians, particularly those in primary care, admit to dissatisfaction in their work. I think the latest numbers suggest that as many as 55% of primary care doctors are dissatisfied. That is much too high of a number. It has long been known that job satisfaction is inversely related to the degree of power that the job holder has in his/her day to day work.  I think that this dissatisfaction in MDS and the powerlessness that goes along with it directly relate to the gain in power that has been achieved by insurers and governmental agencies in the healthcare field. We are at a tipping point. And I am fearful that the regulations in Obamacare may cause many more physicians to "hang it up" due to this dissatisfaction.

     These considerations need to be known to the lay public. Society needs to make some very difficult decisions and there needs to be a new way of thinking about exactly what kind of doctor it wants. It would be difficult to achieve a total "knight" medical core, but we must not drive all physicians through the "pawn" stage to either retirement, or the "knave" stage.

     I would appreciate any comments that you might have, whether physician, physician to be, or patient. What do you think?

M.U.S.C.L.E (Millions of Unusual Small Creatures Lurking Everywhere)

     I have been intending to put another one of my antique toys up on this blog with some background information since a couple of my past blogs about my collection have been popular. But I never thought it would be this toy that would end up featured. Here is how this toy topic aroused my curiosity.
     Every Wednesday I spend 45-50 minutes tutoring a 2nd grader in a neighboring community elementary school. The boy has trouble with his reading and writing and also some difficulty with arithmetic. He has already been held back one year and is still struggling. For each of our meetings his teacher gives us something to work on for at least a half hour. Then for the rest of the time we can do what we enjoy doing. Everything must take place on the school grounds. From the very beginning each time I have brought along one of my antique toys to show to my student. We then have some time to play with the toy or discuss its history. I am finding that David (name changed for privacy reasons), like one would expect from most children, is not really interested in long stories or history. He especially enjoys toys that have something to do with current popular toy characters such as Ninja characters and various other Super Heroes or Fantasy characters. My choice for this particular visit produced requests to bring it back for three weeks in a row.



      Pictured above is a collectible set of toys popular in the United States from 1985 to 1988. They consisted of a package of 10 little 1 inch high bubble gum pink medium hard PVC figures of various strange mutant beings housed in a translucent small garbage can with a lid. These packets were often placed near the check out counters of Target and Toys R Us stores at that time period. They were collectible and my two sons were always looking for a new set to add a rare figure to their collection.
     The name of this toy was M.U.S.C.L.E which stood for Millions of Unusual Small Creatures Lurking Everywhere. I had never looked into the history before, but as is the case for many of my toys there is lots of information on the Internet. I learned that these little figures originated in Japan and there are called kinkeshi. They still lure many collectors even today and there are several websites which still produce regular newletters about the various creatures. These bubble gum colored ones or flesh colored ones numbered 236 different designs. Later the PVC plastic was dyed various of up to 6 colors and these colored ones were mixed with the flesh ones. Collectors still strive to get all of these various designs and colors. Also the United States toys in this line included a random 4-pack of the monsters, and a 28 pack. Also there was a boardgame, a Nintendo game, a championship belt that would hold the wrestlers, and a plastic wrestling ring that allowed fights between your figures.


     The premise of these little toys is fairly straightforward. They represent intergalactic wrestlers striving for dominance in the universe. I didn't know about this premise when I was with David. He thought he recognized various modern characters from various modern fantasy and Super Hero stories. I had to explain that these figures came from another generation, that of my sons' childhood.

 The idea for these toys originated in Japan where they were called kinkeshi, named after the leader of the wrestlers called Kinikuman which means Muscle Man. Originally, like our Superman hero, Kinikuman was really a parody, a goof up of a superhero who was only called on when no other superhero was available. He is a parody of Ultraman dating from the 1960s in Japanese popular culture.  Kinikuman was the leader of the M U S C L E Men. Kinikuman got his power from eating garlic. He has a garlic meter on his forehead.  In Japan, there were also characters called "Cosmic Crunchers" who opposed the MUSCLE Men and whose leader was eventually called Terri-Bull. They and several other well known Japanese characters starred in comics and animated films.  Some of the MUSCLE men wrestlers were parodies of well known Japanese professional wrestlers.  In developing these wrestling figures the Japanese readers and devotees were invited to send in various ideas for wrestlers and many of those ideas were used in this vast number of figures. In Japan there were over 400 such characters. These characters and their stories are still popular and produced today in Japan. Such characters had a brief comeback in the US in 2003 and again in 2011 but these small figures have not been produced in the US since 1988. They were distributed by Mattel, though made in Japan. In Japan action figures of several larger sizes as well as accessories for games and for a wrestling ring were also produced.

     In the United States, these figures may have influenced a later toy produced in the US called Monster in My Pocket. There are several websites for collectors of these various small monster toys as well as websites for monster toys in general. These little wrestlers sell for between 75 cents and one dollar each for common ones. Some online sales of some rare figures reached $10.00 on eBay.

Some scenes from the Japanese comics starring Kinnikuman.

          The above representation is a modern one from Japan showing several members of the Kinikuman family. My collection of little M.U.S.C.L.E. men includes the Kinikuman representation.

     Following are some other views of Kinikuman from the later era when he was no longer such a bumbling superhero,but rather was in some degree of demand in his comic books and animated features.

     Only the two figures Kinikuman and his antithesis, Terry-Bull were named. The rest of the figures sold in the United States were not named. One collector with tongue in cheek has provided names for many of the figures pictured in the large poster below. These are quite amusing and collectors might like to know their favorite figures by these names. I attempted to provide my student, David with some of these funny names (some were R rated and of course I didn't provide them.)  But he preferred to name them according to how they resembled some of the more modern American superheros in various electronic games, and movies. He indeed has a name for almost every one of these figures.

The wrestling rink that was available in the United States.

          Here are some individual photos of some of these figures. Photos of some of my figures are further below.

Here are just a few of the many websites for collectors of these little toys.

The following website is a blog which answers many of your questions about these little figures. It is a very well organized and colorful blog.

http://nathansmuscleblog.blogspot.com/2010/02/collecting-faqs.html

     This website has a number of links to sites that would be informative for M.U.S.C.L.E. figures but also links to other spinoffs of these small figures.
http://www.raumhafen.de/galerie/rubber_guys/muscle/

And the most complete blog on these little toys:
http://blog.uofmuscle.com/course-catalog/history/history-100-an-introduction-muscle-figures-and-toys/

And if you are mainly interested in the Super Rares of these little toys, check out this website:
http://rare-muscle-stuff.tripod.com/id3.html

     In 1985 the following poster was available by mail. It shows many of the collectible figures from the first shipment to the United States of pink or bubble gummed color M.U.S.C.L.E men.

     And here is my lot, or should I say my two sons' lot. It was quite a heap of these things for my student, David, to work himself through, just looking at them and coming up with a name for each one.

     Following are several of the more unique and maybe even horrifying of these little 1-w inch figures.

 

              I had no idea that these figures were to become so popular when I would cave into one of my sons at the checkout counter and purchase one of those little garbage cans full of about 10 such figures. Just recently my oldest son who is now a Chief of Surgery in various capacities at his medical school -- with his family he was home visiting us. I took him into my toy room where all my antique and more modern toys are kept. Out of all the toys, what he was drawn to and what he picked up were these M.U.S.C.L.E. figures. "Oh, wow! Mom, I can't believe you still have these." Then he said wistfully, perhaps remembering a far simpler time in his past, he just simply sighed, "Wowowow!"

To the Caribbean 2014

     Yes, we did get out of this area for a short while this winter. We took our second cruise to the Caribbean in as many years. This time we boarded the Oceania Riviera in Miami and headed out into the northeastern Caribbean. Oceania cruises are known as "foodie" tours. Indeed, the food is definitely a couple steps above the typical. Oceania's two larger ships, the Riviera and the Marina, each also have a wonderful library, board game or bridge room, large lovely lounge on top up front where every afternoon wonderful 4 PM teas are served to the music of their live string quartet. The ship has a wonderful spa, private spa deck for "Veranda" guests and above. There is a coffee bar where baristas stir up excellent brew. I particularly like the Artist Loft, with art classes directed by a resident artist. In the past my main media for art was water colors and water color pencils. But on this cruise our art teacher was a proponent of acrylic and favored the use of only a palette knife. Sure makes clean up easier. For me this was very good practice with this media and method. But one of my favorite pastimes was sitting on our veranda while we were at sea, staring down into the deep indigo waters. We have visited the Atlantic, the Pacific, the Southern Ocean, the Mediterranean, and the Black Sea and Baltic Sea, but none of those waters compare to the indigos and close to shore the various shades of turquoises that characterize the Caribbean. I can sit for an hour just watching the surf as it rolls off the hull of the ship, creating wonderful swirlings and gorgeous turquoises. Once in a while a group of small flying fish will break out of that roiling swirl, at right angles to the ship's path, I am sure, convinced that we are a very large predator.

Our ship,, the Oceania Riviera at Grand Turk cruise ship port.

    Our first port of call was Grand Turk of the Turks and Caicos Islands. This island is quite small and only has one pier. We were the only ship in port. And the port is currently incapable of taking some of the very large cruise ships which I think is a plus. Unfortunately they are gong to add a new pier system which will enable several ships to visit at one time. I think that may destroy some of the charm of the island. The island currently does have a nice developed reception area with nice beaches on each side of that one pier. And there are some very nice boutique shops in this cruise center as well. One of the shops surprised me; it was an Israeli art shop with some Israeli paintings, as well as menorahs, and metal hamsa and chai jewelry and mezuzahs. My husband arranged for us to have a guided tour of the island on of all things -- ATVs. This is the first time we have driven these unique vehicles. Our guide could tell that we were rather inept and kept us mostly on the regular surface roads of the island. Fortunately most of the ship's people just shopped in the boutique stores and used the lovely beach. The island roads were pretty empty. But there was a nice lighthouse to see, some Caribbean flamingos, and there are replicas of the John Glenn Gemini caqpsule around the island because he landed in the waters off the Grand Turk.

Grand Turk Cruise Center beach right next to the pier next to our ship. Many passengers spent the day right here. 

         It was a view of the lovely beach on Grand Turk that I used as the subject for my main acrylic painting of this trip. I wanted to show the blues and turquoises of these Caribbean waters. Here it is:

My version of the Grand Turk beach sitting in a beach chair on the shore side.

Old San Juan

Latte at Cafe Prieto in Guavate.

       Our next port of call was San Juan, Puerto Rico. I visited this island years ago on a pharmaceutical junket and we had rented a car and drove all over the island then. There really is quite a bit to see here. This time we just hired a guide to show us the two forts and give us some history that we had forgotten from the last visit, and to show us a little bit of San Juan. Then he drove us up into the hills behind San Juan to a place called Guavate, famous for Le Choneras. Lechon is pig roasted on a spit. And a restarant that roasts and serves this pig is called LeChonera. The whole name of our destination  restaurant is LeChonera Los Amigos but there are many of these places in Guavate. These are generally rustic restaurants where people dine on picnic tables covered by oil cloth. The meals include the pig (or roast chicken), yams or potatoes, beans, fried plantain, and breads. The food was delicious. It was a Tuesday and it was not very busy at all, so the owner spent some time sitting at our table. He sounded like he was a displaced American by his lack of any accent. But the best part was the cup of coffee afterwards in a neighboring little coffee shop, operated by the owner's wife. This coffee was made from a locally grown premium coffee bean. And of course I had it as a latte. It was absolutely delicious, and fancily prepared by a talented barista. We sat on the deck in back overlooking a deep and lush ravine. It was a great ending to our tour of San Juan.

Leaving the port of Grand Turk.

This is a Royal Caribbean ship called Oasis of the Sea. It carries over 6000 guests

 

. 

 
 Our next port of call, St Marten, is an interesting island. Half is French and half is Dutch. The French side used to be the destination of most tourists, but the local French government decided to go along with the French stand during the US First Gulf War. They voted to boycott all US products and to discourage US tourists. Their efforts succeeded and basically their tourism, with the exception of restaurants, has failed. Their hotels have been turned into rooming houses and condos. Many beautiful big hotels had become totally empty relics. Some still stand empty and deteriorating. All cruise ships now land on the Dutch side which has expanded its tourist facilities accordingly, especially attracting small boating operators who travel from island to island, in addition to the cruise ships. People still take a day trip to the French side, so restaurateurs still do OK there. The island has one famous road along the beach where the large jets landing strip starts just at the edge of the road. People love to sit on the beach at the pilots level as these planes come in. Definitely hard on the hearing.

Peaceful afternoon at the beach; plane after plane coming in just like this.

      The next port of call was St. Barts. We had been their during last year's cruise when we toured the island. We knew that the boutiques just ashore were quite expensive and limited and we were not in the mood for beaching it, though the beach right off the pier is very nice. We decided to just stay aboard. In the afternoon I had an art class to attend anyway, and we were painting for a couple hours.
 

Tortola town, on Tortola of the British Virgin Islands.

Lots of small islands around Tortola.

 I liked Tortola of the British Virgin Islands. We had a nice tour of the island, viewing its beaches and driving to high points in the mountains in the center of the island for overlooks. Tortolas is surrounded by many small islands that welcome visitors. There are a lot of Americans that go to Tortola and spend time. We had lunch in a small outdoor restaurant that was situated among some of these American second homes and the owner of the restaurant was herself an American. It is nice that English is spoken here. I could actually see myself with a second home on this island in particular.

Historic Old Santo Domingo, capitol of the Dominican Republic.

     Next was the Dominican Republic. I think many people have formed an image of the DR which is similar to Haiti. But the DR is definitely different.It is the fourth largest economy in the Caribbean and Central America combined. Many incomes are in the area of lower middle class. There is poverty but it is in the rural areas. There is also crime and the Dominican Republic has been criticized for being too lenient on homicidal crime. Also the South American drug cartels are purported to launder their money through the Dominican Republic, creating corruption. But the infrastructure is good. And tourism has created various protected enclaves on the eastern end of the country and to a lesser extent in the northern central area. Also ecotourism is gaining a foothold and the DR has set aside several large national parks in the central highlands. Our ship docked at La Romana which is located within one of those tourist enclaves. I think most of the ships passengers utilized the beach, the local shopping area, or had signed up for ship excursions that took advantage of the local Caribbean waters. We took a different path and headed for the taxi stand. We were the first ship passengers to arrive there and we saw only two taxi vans. We asked what it would cost to drive to Santo Domingo, the capitol, a distance that would take about an hour and a half. One driver answered us quickly in perfect English. The other driver did not speak English. So the English speaker said "I guess I am your man." It turns out that he had lived in the United States, in Florida for about 8 years. He gave us a safe drive to the capitol, a small amount of information and he put us with a walking guide of the Old Town of Santo Domingo, which has many interesting historical buildings, churches, and shops. There are buildings here from the 15th century because this is the area that Columbus chose to develop, at that time, to become capitol of Hispaniola.
      I wanted to purchase a necklace of larimar beads, which is only mined in the DR. This elderly walking guide got me to a shop where I was able to make my purchase, adding another piece of jewelry to my collection of pieces from around the world. We enjoyed a nice lunch, and then drove back to La Romana and headed to the ship. In all it was a very nice and successful day. We were glad we had taken the opportunity to get out of the tourist enclave and see what the DR was all about.

A boulder of pectolite containing considerable larimar effused through it.

My larimar bead necklace. 

     I want to fill you in a little about this stone -- larimar. In 1916, a local priest asked the government of the Dominican Republic for permission to exploit this stone and even start to mine it but was refused. Then in 1974, a local resident and a Peace Core volunteer found pebbles of the stone that had washed down into the estuary of a stream that originated in the nearby hills and mountains. These two succeeded in getting permission to mine the material and others tracked down the vein of rock where this substance originated. The stone is really taking off in popularity throughout the Caribbean and is even being sent elsewhere around the world to be used in jewelry. The name was created by that local rediscoverer of larimar as a combination of his daughter's name, Larissa, and the Spanish word for sea, mar.  Pectolite is an acid silicate hydrate of calcium and sodium. Pectolite is found in many places around the world, but only in the Dominican Republic does this stone contain the blue color, which has some of the calcium replaced by copper. Geologically, the surrounding stone or pectolite was volcanically created but had holes and cracks in it which were later filled by the blue copper containing silicate creating this stone. Indians in the area had long found pebbles of this blue mineral among beach stones, having been tumbled and polished as they were washed down the hillside and finally onto the beach near the source mountain. Now the original mountain has been found and about 2000 vertical shafts penetrate it where this stone is mined. Apparently there are also a lot of fake larimars, some plastic, some other bluish minerals, especially being sold by vendors on the beaches of the DR .But there is an interesting test one can carefully perform. If you hold the beads or pendant of larimar in a match flame for a few seconds, it will remain cold to the touch afterwards. Plastic of course would melt and your vendor would probably not let you do this. But you must be careful in the case of beads or a strung pendant to not hold the flame near the stringing element for that is often plastic and would then break and release the beads all over the ground. How embaressing! Where I bought this necklace, there was a guarantee of authenticity and there was actually a boulder of larimar there on the countertop as well as boulders for sale. My nice graduated bead necklace cost $300. This is a somewhat soft stone and also in heat and high light, the blues may fade so it should be kept in a cool dark place when not being worn. I especially like how it warms up over time as it lies against the wearer's skin.
 

The trained marching flamingos at Nassau Zoological Gardens and Aviary.

  After a day at sea, we put in to the last port of call, Nassau, of  the Bahamas. We had arranged for a driver to meet us and take us around the island. The first site you see from the ship is the huge and familiar Atlantis resort, for which we see many advertisements on TV. One of the ship's excursions included a tour of the Atlantis and its many different campuses. We had no interest in this and instead saw the rest of the small island. I was surprised at the many lovely streets, roads and the growing resort communities. The Chinese are building a huge resort hotel which is supposed to rival the Atlantis. The port at Nassau can handle at least 8 ships at a time and it can handle the huge Allure of the Sea, sister ship to Oasis of the Sea by Royal Caribbean, which was by the way in port while we were there. Wow, what a ship. Its passenger count is 6200 while our ship has a lowly 1200 passengers on board. We certainly prefer the latter. In fact we even prefer two other ships in the Oceania line, the Nautica and the Regatta which only have 600 passengers.

Leaving Nassau, we say good bye to those wonderful turquoise waters of the Caribbean and it's back to Miami for us.

     

Lawsuit fear in physicians: Is it real?

    On April 6th I posted sort of a political statement about our broken healthcare system. In that article I mentioned that one of the necessities of healthcare reform is tort reform, because fear of lawsuits is driving up the cost of medical care. This has long been my view, and physicians in general believe this to be true. But is it true? Do the statistics support this view?
     I found in a stack of tear sheets that I had saved the following opinion piece from the American Medical News publication, put out by the American Medical Association. This is a 4 year old article but I truly think the statistics are the same now as in 2010. This editorial was published in the September 13, 2010 issue. There is no author listed so I could not write the author for permission to republish his editorial. Therefore be sure to credit the following quotes if you pass this information on.

Lawsuit chances take a toll:
   "Our actions are influenced even when the odds are in our favor. So we save receipts (IRS audit risk, 1 in 100), change the smoke detector battery (fire-related fatality odds, 1 in 1,235), and think twice about standing in the rain (chance of being struck by lightning, 1 in 6,250).
   "When it comes to the chances physicians face in terms of being sued, a new AMA report shows they can expect a lawsuit not as matter of possibility, but of probability. More than half -- almost 61% -- of physicians older than 55 report having been sued. The behaviors that result from those odds should come as no surprise -- such as defensive medicine and practice decisions to shield the doctor from risk. And those actions can significantly affect the cost of care and patient access.
   "The AMA found that overall, 42.2% of the 5,825 surveyed physicians had been sued, with nearly a quarter of them hit with lawsuits twice or more. Obstetrician-gynecologists were among the most likely to be sued, and the measures they have taken as a result are predictable. In a 2009 survey, nearly a third of ob-gyns reported cutting back on high-risk obstetric patients, one of a number of practice restrictions made in light of liability fears.
  " It's a pattern found in other specialties with a high risk of litigation. A June 1, 2005, Journal of the American medical Association study found that 42% of 824 surveyed physicians in high-liability specialties restricted their practice, including eliminating procedures prone to complications, such as trauma surgery. They also avoided patients who had complex medical problems or were viewed as litigious.
   "All told, the AMA lawsuit study found that 95 medical liability claims were filed for every 100 physicians, based on the doctors surveyed.
  " Yet for all the lawsuits, the AMA noted that the figures should not be taken as an indicator that doctors are making more medical errors. In fact, the Association said physicians prevail 90% of the time when a case goes to trial. Most cases never get that far -- 65% are dropped, dismissed or withdrawn.
  "But the cost of fighting a claim is high. The average cost to defend a case was $22,163 for suits dropped, dismissed, or withdrawn, to more than $100,000 for those that went to court. Add to that the anguish of being sued.
  "Defensive medicine is a well-studied result of the liability pressure on physicians, and doctors have been frank in surveys about the topic. A nationwide Gallup Poll of 462 physicians released in February 2010 found that 73% had practiced defensive medicine, such as ordering additional tests, in the previous year to protect against potential liability. The doctors estimated that 26% of health care costs were related to defensive medicine.
   "The same month, an online survey by Jackson healthcare showed that 92% of doctors practiced defensive medicine. The health care management company survey also found that doctors estimated that 34% of health costs were linked to the practice. A study in the June 28 Archives of Internal Medicine reported a similarly high rate of defensive medicine. And 91% of the 1,231 physicians surveyed by the journal agreed that unnecessary diagnostic tests won't end without protection from unwarranted lawsuits.
   "The AMA has long supported the well-proven tort reform of caps on non economic damage awards, most notably in California and Texas. It continues to push for that fundamental reform at the national and state levels. The AMA is keeping a watchful eye on alternative solutions to the medical liability problem. In June, the Dept, of health and Human Services awarded $25 million in grants to test alternatives such as health courts and early compensation programs. The 20 grants, issued to health systems and states, fund projects that will explore ways to improve physician-patient communication and reduce common medical errors, among other things.
  "The AMA successfully advocated for funding of the demonstration projects. They are a way of increasing the odds that widespread tort reform will become a reality, and that the health care system can operate without the costly burden of a litigation fear factor."

     I can certainly recall my years of practice. I was sued twice. One time it was not a malpractice suite, but rather a defamation suit finding fault with something I wrote in a letter for a patient which referred to the patent's husband. There was a small settlement for that suit. The other suit was a malpractice suit. I was the primary care doctor and my clinic, a gynecologist from the clinic, a radiologist from the clinic, and myself were sued for a mistaken diagnosis. It was a very strange case and involved a mistake made by a previous doctor in which a patient had two IUDs placed at different times and then one and only one removed. We doctors were not aware there was a second IUD which could be causing pelvic pain, even though an xray taken at our clinic did show the second IUD. I recall the anguish just in my case during this lawsuit and I was only peripherally involved in the case.
     In the article above, the brief referral to the anguish that a lawsuit brings is mentioned but not dwelt on. I can vouch that there is indeed anguish. The second guessing that the physician does over and over again, all night long, and intensifying around any legal meetings with the lawyers or around court events such as depositions and court appearances. These thoughts can be mentally paralyzing.  I have often spoken casually with attorney friends and acquaintances. They do not seem to understand this anguish. They say that we physicians should just look at a lawsuit as the 'cost' of doing business. They say we should not take it personally; that we should just go through the legal procedure without feeling that we are under attack. Indeed, I cannot imagine any physician who cares about and for his patients being able to maintain such a distanced and in a way calloused view of lawsuits and their progress. We all take out profession very very seriously and worry about our patients, our care of them and the medical decisions that we make 100 times every day. We worry about making an error, or missing something that we feel we should not have missed. And this worry makes us do all sorts of things to try to make lawsuits not happen.
  

  

A New Surgeon General -- "Dr. Murthy are you up to the job?" Now Congress are you up to the job?

     I am a retired physician but I still subscribe to several medical journals. I still get JAMA Internal Medicine. My February issue arrived on February 4th, the actual day during which Dr. Murthy would appear before congressional hearing to be confirmed as the new Surgeon General of the United States, the so called Doctor of America.

     I opened the pages of JAMA and there on the first page after the Contents was a Viewpoint by Nathaniel Morris, a medical student at Harvard Medical School. The title of the Viewpoint was "A To-Do List for the Next US Surgeon General." I read through this article and strongly agreed with Mr. Morris on points which he has made very precisely and understandably.

     Now, I have not frequently written here about our broken medical care system. But I was impressed enough with this young man's viewpoint, that I immediately emailed him and asked his permission to place his "Viewpoint" here on my blog. He almost immediately answered and gave his permission. However, he stated he had already posted the Viewpoint and a lead in explanation on the following CNN website. I still am concerned that most people will not find this posting or choose to open it up. Therefore I am posting this on my internationally read blog in the hopes that it will stir interest and define what I think this new Surgeon General's job should be. Check this posting out by clicking on this website. If you choose not to read the lead in by Mr. Morris, scroll down about a page and find his republished "Viewpoint" taken directly from the JAMA piece:

http://www.cnn.com/2014/02/04/health/morris-surgeon-general/index.html?hpt=he_c2ece.


     In reviewing the bibliography for the JAMA "Viewpoint" I see that Mr. Morris wrote about the same words in JAMA. I do so agree with much of what he says. We do need some very innovative leaders in the field of medicine to think outside the box on our healthcare system. Unfortunately Obamacare is not going to do it by itself. In fact it will increase the cost of medical care dramatically. That is already happening. Just yesterday, at the diner where we often eat breakfast, I heard the waitresses and other employees and even the owner talking about how much insurance premiums have already gone up. One waitress had a bad health year, had a breast biopsy which fortunately had a benign result, and she had shingles. This several months was the first time in her life that she had utilized the healthcare system with the exception of the births of her children. She was totally shocked about the costs, the insurance papers one has to try to understand, the co pays and in general the "brokenness" of the system. Now it may well be that the insurance companies are already increasing costs only because they view an Obamacare that they think will itself increase costs. But both the provider side of medicine and the consumers need to review their expectations of medical care. On the medical care side, we need continued research to provide evidence to support the expensive and also commonly used medications, and procedures that we physicians, nurses, physical therapists, and counselors use. On the patient's side of the issue, we need more education and a public that is interested in learning about the various issues of medical care so that they can understand what their doctor is telling them, instead of often acting in an adversarial fashion. We also need something that no government healthcare authority has ever been willing to tackle -- that is tort reform. Our litigous society forces all health care providers to order more tests, more drugs, and to spend more time and money to protect themselves from a lawsuit than is required by the normal standard of care. This is where the greatest thinking outside the box is required.

     Unfortunately at a time when we most need a surgeon general, and one who is well educated and dedicated to the job, our partisan politics are holding up the process of getting one. Dr. Murthy just mentioned gun control, some form of which the American Medical Association, the American Pediatric organizations, and the vast majority of American physicians support in some form, Even though he has said that his main focus will not be gun control, but rather obesity, tobacco, and mental health, the National Rifle Association and their lobbyists seem to have succeeded in blocking at least temporarily Dr. Murthy's appointment. This is not the way to move ahead in fixing the broken health care system. It is mightily discouraging! Read below from this March 18th article describing the current events relating to Dr. Murthy's approval.

http://commonhealth.wbur.org/2014/03/doctors-vivek-murthy-blocked

     Now I am a fiscal conservative and generally support conservative causes. But I am also a doctor and there is no doubt that gun violence is currently an overwhelming problem. That is why most doctors support some sort of gun control. But politics have entered into the fray in choosing a surgeon general at a time when we very much need one.

     One more absolutely up to date article on this topic from April 6:

http://www.philly.com/philly/blogs/fieldclinic/Taking-Aim-at-the-Surgeon-General-Nominee-Misses-the-Point-.html:

     I am stepping off my soapbox for the time being!

Dreaming: Gardening in January!

 In the dead of our Wisconsin winter, I am dreaming of what will eventually come:

Dream of the flowers to eventually come!

  A three entry gardening journal for the brutal winter of 2014:

January 20, 2014.  From reading my blog, I am sure most of my readers know that I love to garden. Well, this winter except for the southern tip of Florida, and some areas of the west coast of our country, most of this country has not been able to even get outside for a safe and comfortable walk, let alone dig in the dirt and garden. Well, in my case, the desire overcame the obstacle. My kitchen counter and some badly overgrown succulents in pots in my bathroom provided the chance to get that black dirt under my fingernails.    
     So I went to my favorite store: Stein Gardens and gifts. They had a sale on small succulents. Between the few I purchased and cuttings from my overgrown ones I was able to make these pots look delightful and fresh. I also potted up some tip cuttings from these long and winding stems of echeveria and aloe and I plan to use these little cuttings that root as "crops" in this coming summer's fairy gardens. Of course, the problem I will have is the white tailed deer. They loved these little succulent tips last year when I tried the same thing. I will have to protect them out in my wooded area when I am not around there. I plan to make a dome of chicken wire and fasten it into the ground. I hope that will protect them when I am not there. Otherwise I will be spending a fortune on spray repellents.  Anyway here are some of my replanted pots. Aren't they pretty?

Whirlpool surround with my succulents all newly potted up.

Close up of the freshly potted plants.

Close ups

     While I was at it, I decided to take cuttings from two very large and now leggy geranium plants growing in my bedroom. My hope was that I would have a large supply of newly rooted geraniums to plant in May and June. Unfortunately, our trip to the Caribbean this year came right in the middle of this rooting procedure. All of those beautiful cuttings turned brown and dried up. I don't know if the soil got too dry or what. Not a one of them developed any roots. Oh, well. Anyway, it is indeed possible to garden in January. Give it a try. It boosted my mood for several days. Only the next snowstorm sucked some of the ebullience out of me.

Geranium cuttings -I'll have lots of these pretty bicolor leaved orange red plants.

     March 29, 2014. I can't believe that the winter is still going on. I think, we have had one of the coldest March's on record. This last Monday in Milwaukee, the temperature high was 21 degrees. The temperature low was in the low teens and the wind chill was in the single digits. So again my fingers itched to do some planting. And it is impossible to even begin the clean up of beds outside. We still have large piles of snow where it was plowed off our driveway. And there are still drifts in shady areas. AND we are so very tired of this! I decided to do some more gardening indoors. I am trying those geranium cuttings a second time -- the ones that failed in February. So far they seem to be surviving. I really liked this particular geranium with the green and reddish brown leaves and bright coral red blooms. I also brought up some more plain geraniums that I had overwintered by uprooting them, and hanging them upside down in my wine cellar which is nicely humidified. They were all sprouting. I potted them up and the shoots are currently turning upright and I hope they will start to grow.

These are the geraniums that have hung upside down all winter in my baement.

This one even tried to bloom under those circumstances. Now they are growing.

April 5, 2014:  The first morning that it has felt reasonably nice on Lake Michigan. Temperature was about 46 degrees and only a very slight breeze was stirring the trees. I went up to our third floor observation room where I overwintered my fuchsia plants, Artemesia, verbena hanging baskets and various other annuals. It's also where several pots of foxglove seedlings are now growing actively. The temperature up there has risen into the 50s and all plants are actively growing. I fertilized them about 10 days ago and I added some systemic insecticide to the fuchsias as they tend to get infected with white fly. Now all plants needed watering. Happy to see some activity up there at least. I made a tour of our property this morning. There is really not much coming up. I can see a few tips of daylilies, but no daffodils evident out in my wild areas. No tulips near the house yet. Many of the irises that I divided and transplanted all over the place last fall are shooting up leaves. So it looks like they all survived, Though I don't know whether I will have any blooms this year after such a massive transplanting upheaval that I performed. I have raked 1/2 of my back borders near my house, and thought to do the other half today but the wind came up off the lake and it was kind of bitter. Instead I moved into my back porch. With the sliding windows all closed it was nice in there. I began cleaning and preparing all my fairy garden ornaments to get them ready for placing in my woods. And I planted nasturtium and sweet alysium seeds. I have never done that before-- seeded annuals inside to get them ready for outdoor transplanting after frost risk has passed. It always seemed so much work. But with this cold winter and spring, it gives me a sense that I am gardening. And I think the winds off Lake Michigan are going to keep it cold around here. I suspect plants will need this head start.

Here is the time of year we are aiming for. These are the orioles that visited our orange feeder last year. It will be a few weeks before they come this year.

A goldfinch already in its summer feathers, and white crowned sparrows.